



PRACTICAL TREATISE 



DISEASES OF CHILDREN; 



BY 



JAMES STEWART, M. D, 



Ex toto non sic pueri, ut viri, curari decent. 
Celsus, De Medicina, Lib. iii vii. i. 




WILEY & PUTNAM 



M DCCC XLI. 






., 









4rcS 

GO 



Entered according to the Act of Congress, in the year 1841, hy 

James Stewart, 

Tn the Clerk's Office of the District Court of the United States, for the Southern 

District of New-York. 






3~X- 3 



J. Van Norden & Co., Printers, 
27 Pine-street, New-York. 



TO 

HUGH McLEAN, M. D. 

OP NEW-YORK, 

THIS TREATISE 

ON 

THE DISEASES OF CHILDREN 

£s most 3&esj>ectfull£ Eixscvfftclr, 

IN TESTIMONY 07 

THE RESPECT ENTERTAINED FOR HIS HIGH PROFESSIONAL ATTAINMENTS, 
HIS EXTENSIVE EXPERIENCE, 

AND THE 
UNIFORM URBANITY AND KINDNESS WHICH CHARACTERIZE HIS DEMEANOUR, 

A3 WELL TOWARDS HIS PROFESSIONAL BRETHREN, 

AS TO ALL WHO ARE HONOURED BY HIS PERSONAL ACQUAINTANCE. 



JAMES STEWART 



PREFACE. 



The rapid advancement of physical science, in the continu- 
ally new application of its principles to the necessities of man- 
kind, demands, from time to time, a review of the various sub- 
jects which it embraces, and a digest of the most prominent 
theories, and their practical deductions, which have been elicited 
by the laborious and enlightened investigations which charac- 
terize the present day. 

In the department of medicine especially, the numerous trea- 
tises in its different branches bear evidence of the vast amount 
of interest felt in the investigations of the numerous facts exist- 
ing throughout professional records, and in the occasional 
examination of prevailing doctrines. 

That branch of medicine which embraces the consideration 
of children's diseases, has received a full share of the attention 
of the cultivators of medical sciences, both in Europe and 
America ; and several works, abounding in practical experience 
on this subject, have issued from the press. 

It cannot, however, be denied, that a treatise, in which the 
whole subject of disease at the important period of childhood, 
is now needed ; especially as the actual condition of disordered 
parts, the result of morbid action, has of late received more 
than ordinary attention from the cultivators of pathological 
anatomy ; a new era, it may be said, having commenced in the 
investigation of the diseases of man during the important period 
of growth. But it is unfortunate that many of the industrious 



VI PREFACE. 

cultivators of morbid anatomy have rarely applied their investi- 
gations to strictly practical purposes, which should be the object 
of all medical inquiry. 

To attempt, therefore, the condensation of existing knowledge 
from facts, both from his own sources and from the recorded 
experience of others, and thus present, without the detail of 
cases, a treatise on the affections of children, in which the sub- 
ject may be considered with a direct practical bearing, is the 
object of the author in the present essay. 

In the required investigation, a great many works have been 
consulted, which it is unnecessary here to enumerate, as refer- 
ences have been made to them throughout these pages. That 
of Professor Schill on Pathological Semeiology, translated by 
Spillan, has afforded material assistance on the evidences of 
existing disease, but from the nature of the subject no reference 
has been made to this work. 

For access to many of these works, the author is indebted to 
Dr. John W. Francis, whose extensive and valuable library, 
rich in some of the rarest treatises in professional literature and 
the kindred sciences, was freely placed at his disposal ; and it 
affords him no little gratification to avail himself of the oppor- 
tunity now presented, to express his sincere acknowledgments 
for this and many similar acts of friendship. 

New-York, April, 1841. 



CONTENTS. 



PAGE. 

Preliminary Observations, 1 

Vital Functions 22 

Respiratory System, 22 

Physiology of the Respiratory 

System, 22 

Signs of Disease from the Res- 
piratory System, 28 

Diseases of theRespiratory Sys- 
tem, 32 

Asphyxia, 32 

Bronchitis, 40 

Pneumonia, 49 

Pleurisy, 61 

Coryza, 64 

Croup, 66 

Inflammatory Croup., 70 

Spasmodic Croup, 91 

Pertussis, 97 

Circulatory System., Ill 

Peculiarities of the Circulatory 

System, Ill 

Signs of Disease from the Cir- 
culatory System, 115 

Diseases of the Circulatory 

System, , 117 

Cyanosis, 117 

Infantile Remittent Fever, . . 120 

Natural Functions, 131 

Digestive System, 131 

Peculiarities of the Digestive 

System, 131 

Signs of Disease from the Di- 
gestive System, 140 

Diseases of the Digestive Sys- 
tem, 143 

Stomatitis, 143 

Tongue-Tie, 155 

Morbid Dentition, 156 

Tonsillitis, 164 

Cynanche Maligna, 167 

Protitis, 174 

Diseases of the Stomach and 

Intestines, 178 

Indigestion, 178 

Diarrhoea, 194 



PAGE. 

Digestive System — 

Feculent Diarrhoea, 195 

Serous Diarrhoea, 200 

Bilious Diarrhoea, 202 

Mixed and Chronic Diar- 
rhoea, 205 

Cholera Infantum, 212 

Hepatic Affections, 227 

Constipation, 229 

Worms, 235 

Gastritis, 251 

Enteritis, 254 

Dysentery, 262 

Peritonitis, 266 

Herniae, 268 

Excement System, 271 

Peculiarities of the Excement 

System, 271 

Signs of Disease from the Ex- 
cement System, 279 

Diseases of the Excement Sys- 
tem, 283 

Scrofula, 283 

Tabes Mesenterica, 304 

Rickets, 318 

Incontinence of Urine, 323 

Dysuria, 326 

Retention of Urine, 329 

Diabetes, 331 

Cutaneous Diseases, 337 

Ncevi Materni, 346 

Verrucae, 348 

Crinones, 349 

Alopecia, 350 

Encausis, 350 

Pernio, 354 

Vesication, 356 

Intertrigo, 356 

Strophulus, 357 

Prurigo, 359 

Impetigo, 360 

Porrigo Larvalis, 362 

Erysipelas, 365 

Jaundice, 369 

Urticaria, 374 



vin 



CONTENTS. 



PAGE. 

Ezcement System — 

Lichen, 376 

Roseola, 377 

Eczema, 378 

Herpes, 380 

Purpura, 381 

Furunculus, 383 

Psoriasis, 384 

Porrigo Favosa, 385 

Tinea, 386 

Ecthyma, 391 

Pemphigus, 392 

Rupia, 392 

Scarlatina, 393 

Rubeola— Measles, 424 

Variola— Small-Pox, 436 

Varioloid, 449 

Varicella — Chicken-Pox, . . . 452 

Vaccinia — Co w-Pox, 455 

Vaccination 461 

Syphilis,...' 478 

Scabies, 483 

l 



PAGE. 

Animal Functions, 486 

Nervous System, 486 

Peculiarities of the Nervous 

System, 486 

Signs of Disease from the 

Nervous System, 490 

Diseases of the Nervous System, 494 

Convulsions, 494 

Chorea, 502 

Hydrocephalus, 506 

Acute Hydrocephalus, 506 

Chronic Hydrocephalus, 529 

Ophthalmia, 534 

Otitis, 536 

Motor System, 537 

Peculiarities of the Motor Sys- 
tem, 537 

Signs of Disease from the Mo- 
tor System, 539 

Diseases of the Motor System,. 540 
Abscess of the Hip Joint,. . . 540 
Club-Foot, 542 



PRELIMINARY OBSERVATIONS. 



In considering the diseases of children, that view of the subject 
which is the most natural^ and consequently most in accordance 
with sound philosophy, is that which is in closest connection with 
the successive developement of the various functions ; for upon the 
unimpaired discharge of the functions of every organ, the healthy 
condition of the system, especially in a growing state, absolutely 
depends. Besides this general consideration of the influence of 
growth in the successive operation of the assimilating process, 
and of the gradual developement of the animal frame towards that 
state of perfection necessary for its ultimate adaptation to the sphere 
in which it was designed by its Creator to move, a more particu- 
lar attention to the alteration occurring in the minute capillary 
circulation is necessary, at a period of life when growth forms the 
most prominent phenomenon. 

In the organized frame during the period of increase, where the 
successive formation of parts is so signally controlled by the pre- 
vious condition of the separate tissue, as well as of the entire body, 
this investigation into the molecular changes, constituting intersti- 
tial growth, becomes necessary, for the proper study both of the 
healthy and diseased state. This mutual dependence of the va- 
rious functions of the human frame, and the chain of causes and 
effects as occurring at all periods of life, have long been the subjects 
of study : those arising solely from the developement of parts during 
the period of infancy and childhood — the time allotted to the in- 
crease of the body — and the effects arising from their arrest or 
derangement, have received less attention from medical philoso- 
phers. That some cause must exist in addition to those to which 
adults are exposed, to predispose children to disease, and to pro- 
duce the great mortality among them, is a self-evident truth. And 
this cause doubtless has its origin in the process of developement, 
or in the necessary dependence of successive developements ; as 

1 



4, PRELIMINARY OBSERVATIONS. 

the occurrence of a suspension of the growth of a part must, with' 
out any other cause, be productive of disordered action, and thus 
be a source of disease. The excess of vitality, and the consequent 
redundancy of excitability, is a peculiar condition of the state of 
infancy and childhood, in close connection with the developement 
of the whole body, and a fruitful source of disease. 

When the effects of growth are better understood ; when the 
labours of the human and comparative physiologist — which have 
already opened to our view some of the hitherto deeply hidden 
mysteries of our physical nature — shall be extended to the investi- 
gation of the principles which more immediately direct the de- 
velopement of unformed parts, may we not confidently anticipate 
the time when the nature of morbid affections in children will 
become better understood, and more under the control of the phy- 
sician % The consideration of these subjects suggests an extensive 
field for cultivation, the magnitude of which increases with the 
contemplation of it in all its relations, and the difficulty of its proper 
study : it is a task for which the author is conscious that his abilities 
are totally inadequate ; indeed it is one which, in the present state 
of science, it can scarcely be expected can be presented to the 
consideration of the physician, as a subject on which to found 
exclusive principles of practice for the treatment of disease. 
Although deeply impressed with the importance of this view of 
the additional causes of children's diseases, he will not, in the 
following pages, attempt to apply them to the various affections to 
which children are subject; but will be contented with suggesting, 
in the systematic arrangement, the broad principle of the succes- 
sive developement of the functions, as the boundaries and landmarks 
of their morbid affections, and the process of increased capillary 
circulation attendant on growth, as the chief predisposing cause of 
the frequency of disease among them. 

The division of the subject adopted in this work, is that founded 
on the functions of the human frame, as the most natural; and the 
one which is most practically applicable, is that proposed by Galen, 
and which, until the time of Bichat, was the division generally 
adopted. Bichat arranged the functions into those which relate to 
the preservation of the individual, and those which relate to the 
preservation of the species. The former were again subdivided 
into several minor divisions. Such an arrangement of the functions 
is inapplicable to the subject here undertaken ; but that proposed 



PRELIMINARY OBSERVATIONS. 3 

in former days is here adopted — a division which is in fact the 
foundation of the various suggestions of physiologists made in later 
times. The diseases of children have therefore been arranged 
under the three divisions of the functions of the human body, which 
are the most natural in the order of their developement, and which, 
on this account, may become the sources of disease. 1st. The 
vital functions, or those which are essential to life, and without 
which animals cannot exist; as the circulation and respiration. 
2d. The natural functions, those which are instrumental in repair- 
ing the several losses which the body sustains ; as digestion, chylifi- 
cation and secretion, which may be suspended for a time without 
destruction of life. 3d. The animal functions; those by the agency 
of which we hold communication with the surrounding world ; as 
the motor and nervous systems. 

Such is the arrangement proposed ; and with this system, the 
whole subject can be properly brought under consideration, in the 
order presented to us by the successive appearances and develope- 
ment of the great functions of the human body ; commencing with 
the first in the natural order, that of the simple organic function of 
circulation, and terminating with the last in the succession, which 
gives the young being his place in the scale of animals and created 
intelligences. 

In considering the various subjects treated of in this work, those 
phenomena which depend on the derangement of vitality, so liable 
to occur when this abounds — on the manifestation of disease during 
life — the disorder of function, and the mutual dependence of the 
different organs, will be regarded as of importance in considering 
the pathology and treatment of disease ; and as in many cases 
preceding the sanguineous congestion or disorganization of the 
solid portions of the body revealed on dissection. How important 
soever the ultimate effects of deranged action, the destruction of a 
part exhibited on autopsical examination may be, — and none can 
be more sensible of its importance than the author, — it is evident 
that too much reliance has in some instances been placed on these 
revelations as the only guide for us in practice, without duly con- 
sidering that they ought rather to be regarded as the effect of pre- 
vious diseased action. Disorganization of structure is the evidence 
of the loss of vitality in the affected part ; it is the consequence, not 
the essence of the disease : we should not therefore regard this 
condition as in ev*y instance giving all the information we need, 



4 PRELIMINARY OBSERVATIONS. 

and as our sole guide in the treatment, but only as a mark of what 
has pre-existed, and which alone we are to consider as the disease. 
Anatomical investigations are of great value in detecting the 
changes which occur from diseased actions in the various tissues, — ■ 
to determine the nature of these alterations and their relations to 
the symptoms, but are of little use in ascertaining the nature of 
disease producing these alterations. 

An exclusive attention to the solids, when investigating disease, 
and the almost entire predominance given to organic changes, by 
some cultivators of pathological anatomy, have caused the alterations 
which occur in the fluids — constituting five sixths of the body of an 
adult, and in children a predominance beyond estimation, while in 
the early embryo almost its whole substance — to be left altogether 
out of view; and although the pathology of the humors may have 
been in former times carried to an absurd extent, yet it is equally 
absurd in the present day to pass to the other extreme, and to deny 
the existence of changes in this portion of the materials of the body, 
when it is considered that the solids themselves are dependent on 
the proper proportion of the constituents of the blood for their 
healthy condition. It might easily be supposed that the complica- 
ted nature of this fluid would readily expose it to alterations, and 
that morbid changes would occur in a rare as in a dense part of the 
structure; for the simple consistency of the part can have but little 
influence on its liability to alteration, except that the harder and 
more permanent parts of the body would be the least exposed to 
these alterations. It may not be out of place to refer briefly to a 
few well known changes, as the facts they prove have some bearing 
on the subject under discussion. 

The blood may be deficient in some of its component parts, or 
may possess an excess of one or more of its elements ; as the 
fibrine, albumen, hsematosine, or the saline ingredients. The 
spontaneous separation of the cruror and serum shows at times a 
difference in its process ; the former being firmly coagulated and 
cupped, and the latter in appearance excessive in quantity. Again, 
the opposite condition exists, the coagulum less dense, while the 
serous part is apparently small in quantity. In other instances it 
exhibits the albumen on the surface of the coagulated mass, which, 
in connection with the fibrine, forms the buffy coat. Various other 
changes may occur, as has been proved by experiments on the 
lower animals by Gendrin, Dupuytren, Noger, Dupuy, Cruveil- 
heir, Magendie, Andral, and others. 



PRELIMINARY OBSERVATIONS. 5 

Its dissolved condition was long since observed by Sydenham 
and Huxham,* and more recently by Dr. Stevens.t With regard 
to the important influence of its coagulability, the experiments of 
Magendie, contained in his recently published lectures on the blood, 
give very striking illustrations;! having demonstrated that this 
property is an indispensable condition to the free and regular 
continuance of its movements in the capillary system. Of what 
inconceivable importance then must it be to the growing child, and 
what a source of disease, where all depends on the proper pro- 
portion of its ingredients ! Chemical tests will also detect the 
occasional alterations of the blood ; that drawn from a variolous 
patient is acid, as is shown by placing a piece of litmus paper in 
the serum, according to the experiments of Magendie, in the work 
just mentioned :|| other chemical changes are also given by him. 
Many diseases which have been considered as new tissues, as 
medullary sarcoma, melanosis, etc., ought to be regarded, according 
to the views of Andral, as the effect of altered secretion ; for every 
degeneration of a part, on considering the process of its formation, is 
but an alteration of the circulatory and secretory process. 

It is evident, then, that both solids and fluids are affected in dis- 
eased action, and the cause must be sought in that peculiar proper- 
ty of organized structures denominated vitality, existing in all parts, 
on which the growth and maintenance of the body depend. If the 
healthy increase, and the property of resisting the tendency of all 
such bodies to decomposition, either in whole or in part, are to be 
referred to this power, any disturbance of it must be attended with 
a derangement of the functions of the part, and if continued, with 
an alteration of structure. So long as the vital property is in nor- 
mal exercise, so long will the system continue in the healthy dis- 
charge of the functions of digestion, nutrition, circulation, etc., 
the relative actions of deposition and absorption will be main- 
tained, and the health of the individual effectually preserved. As 
this property is in exercise in all the body, and in every separate 
portion of it, both solid and fluid, in a manner which may be 



* On Epidemics, Vol. II., p. 68, et seq. 

t Observations on the Blood, read at the College of Physicians and Surgeons, 
May 3d, 1830. 
t Lectures on the Blood and its Changes. — Philadelphia edit. p. 12. 
II Page 20. 



b PRELIMINARY OBSERVATIONS. 

regarded as in a degree independent, so any particular abnormal 
alteration of its action must be attended with a corresponding- 
change in the part experiencing these alterations. This will 
appear more evident when the ordinary manifestations of vitality 
are considered, and which it is necessary to examine, that the views 
here suggested as to the commencement and progress of diseased 
actions, and the important agency of the developement of the body 
in their production, may be the better understood. 

The idea of life most in accordance with the present advanced 
state of physiology, the result of continued investigation, and the 
illustrations which have been afforded by comparative physiology, 
is not that of an imaginary principle presiding over the whole 
system, directing and controlling its operations — an idea which was 
formerly adopted to explain what had eluded the closest re- 
searches, by referring the phenomena exhibited by a living body to 
a separate agent or power — but as one of the essential properties of 
organization manifested in an assemblage of phenomena, which 
distinguish the two great classes of the organic kingdom, vegetables 
and animals, to which alone these phenomena appertain. All orga- 
nized matter possesses, in its very constitution, certain properties 
so peculiar in their nature, that upon the application of certain 
stimuli, those phenomena are produced which are known as vital 
actions, the effect of properties not superadded after the formation 
of the organized mass, as formerly understood — an elementary sub- 
stance controlling the body, but, as is most natural to believe, and the 
most agreeable to the uniform simplicity observed in works of the 
Creator, imparted on the original formation of the classes as a part 
of their constitution : each class manifesting its own peculiar 
series of phenomena, by which it is distinguished from the other, 
and both thereby widely separated from the inorganic kingdom ; 
while the analogous action of each tissue in both classes is sufficient 
to prove the identity of this principle or property of organization. 
It has been supposed to be a peculiar principle of action, an aura 
or gas, an abstract power presiding over the body, and known by 
the names of vital principle, anima, archaeus, etc., by Aristotle, Van 
Helmont, Stahl, and others, even of quite recent times, among 
whom is the physiologist, Muller.* From this it would appear, 

* Elements of Physiology, by J. Muller, M. D. Translated by Baly, Loud. 
1837, p. 28. 



PRELIMINARY OBSERVATIONS. 7 

that a controlling anima was supposed to exist in vegetables as 
well as in animals ; but whatever be the precise nature of the cause, 
all observation would lead us to the conclusion, that it is not thus 
that the phenomena of vitality seen in plants are to be explained, but 
that they arise from an inherent property, common to the whole or- 
ganic kingdom, distinct from the addition of the nervous system in 
animals, and from that principle superadded in men, which, while it 
adds perfection to his organic system, by placing him in the highest 
part of the scale of animated nature, is, at the same time, the connect- 
ing link between him and the incorporeal intelligences of the spiritu- 
al world, the perfection of that remarkable gradation which the ob- 
serving naturalist has traced as pervading the two divisions of the 
vital kingdom. 

Of the precise nature of the cause of the phenomena of life, it is 
impossible for us at any time to have any clear comprehension ; but 
some knowledge of its general manifestation, and consequently, the 
nature of its connection with an organized structure, will be ob- 
tained by considering the analogy observable throughout the vege- 
table and animal world. 

Under different modifications, vitality exhibits its phenomena in 
every organ in the vegetable and animal structure, in both, the great 
agent of nutrition; and in the latter, that also of the functions of re- 
lation, by which this class is adapted to the surrounding world in a 
manner different from the other class, and thus from the assemblage 
of its manifestations in some sense independent, presents to us at 
once the general principles from which we may infer that it is the 
inherent property of the organization. 

In the propagation of plants and animals, there is an analogy in 
the process of generation. In both, the first manifestation of vital 
action is in the germ — a fluid possessing the power of spontaneous 
life — and the action is that of simple developement. As the differ- 
ent parts are successively formed, vitality exhibits itself by phe- 
nomena, peculiar to the different parts formed. Circulation, depo- 
sition, absorption, contractility, follow each other in both classes, 
both growing by nourishment absorbed from analogous parts, — the 
plant from the albumen of the cotyledon of the seed ; the fcetal chick 
from the vitellus or albumen of the egg. The growth of the fcetus 
bears a close resemblance to the entire vegetable life, from its at- 
tachment and dependence on a source exterior to its own body for 
its entire support, and may in one sense be termed a zoophyte. 



8 PRELIMINARY OBSERVATIONS. 

The young animal, unlike his after mode of existence, obtains his 
nourishment by absorption, or transmission of the appropriate sti- 
muli for developement and support. Plants may be produced by 
offsets or cuttings : in the lower animals, zoophytes and polypes, 
propagation is effected in the same manner. Growth and nourish- 
ment are here produced by the inherent vitality of the separated 
slip or portion of the plant or animal, entirely distinct from any 
supposed centre of vitality which exists in the germ or matured 
structure ; the principle of developement being excited into activity 
by the influence of heat, moisture, and perhaps other causes ; of 
which, in our present state of knowledge, we have but a very imper- 
fect idea. 

Plants, like animals, possess a circulating system ; arteries and 
veins, sap vessels or lacteals, and lymphatics. The arteries arise 
from the root, and convey nourishment upwards ; next to these are 
the veins, which return the elaborated sap from the leaves to the 
new layer of the liber.* The sap vessels, corresponding to the 
lacteals in animals, convey the nourishment to the body of the 
plant as the chylous vessels do from the intestines of the animal. 
The lymphatics of the plant are found immediately beneath the cu- 
ticle, and from the direction of the valves appear to be intended to 
pass the fluid in the same direction as the veins. Plants, then, have 
a double circulation ; the arteries and lacteals to convey the sap up- 
ward, the veins and lymphatics to pass it in the opposite direc- 
tion.! Plants also possess, equally with animals, vessels for cuta- 
neous transpiration. Some of them, as the sunflower, Helianthus 
annuus, give out an enormous quantity of perspirable fluid com- 
pared with their bulk. 

A compound fluid exists in vegetables, corresponding to the blood 
in animals ; and as the secretion of substances possessing various 
qualities, from that of a simple article of nourishment to one highly 
destructive to animal life, occurs in the same plant, so does the blood 
separate in animals, asin some of the reptile tribe, secretions 
for nourishment, and a poisonous juice, destructive to the life of 
animals, for defence. 

Respiration is a process which is continually taking place in 
plants as well as in animals : and, in the fungi, almost as actively 
as in animals. 

* Smith's Introduction to Botany, p. 56, et. seq. 
t Wildenow's Introduction, p. 236. 



PRELIMINARY OBSERVATIONS, V 

Contractility, on the application of stimuli, is another analogous 
function existing between vegetables and animals, in neither con- 
tinuing longer than the existence of vitality. The examples of 
this contractile irritability in vegetables, corresponding to the irrita- 
bility of the muscular fibre, are very numerous, and in some in- 
stances so allied to sensibility and consciousness, and consequently 
to the appearance of voluntary power, as to have given rise to the 
fanciful idea of the existence of a brain and the corresponding 
passions. 

Vegetables, in some instances, like some of the insect and reptile 
tribe, annually exfoliate their cuticle, and thus give another in- 
stance of the analogy of vital action, which, in both classes, thus 
entirely leaves a portion of the body destitute of this sustaining 
property of organization. 

Both plants and animals sustain themselves uninjured under 
great changes of temperature ; and both classes, from the existence 
of innate warmth, have been known to affect the thermometer. 
Deciduous plants resist the severity of the winter's cold, and bear 
removal without being injured. So also, eels, newts, and leeches 
have been frozen in ice, torpid, and to appearance dead, and upon 
thawing the ice were restored. The first mentioned animals have 
been conveyed thousands of miles in Russia, and been completely 
revived after carefully thawing them. Plants have also been found 
to resist extremes of heat. Flowers nourish in the neighbourhood 
of volcanoes, where the thermometer stands at 210° ; and confervas 
grow in springs, at a temperature of 212°. Fishes also have been 
seen swimming in water at 15S°, while men have often been ex- 
posed uninjured to a heat of 264°, and for short periods even 
higher than 300 c . 

Both animals and vegetables afford instances of their amphibious 
nature ; the tortoise, eel, etc. among the former, the rush, rice plant 
and algae, among the latter. 

Animation may be suspended in both, often for a surprising 
length of time, while the animating property continues to preserve 
the organic frame. This is seen not only in seeds and eggs, but 
also in the matured structure. The torpidity or hybernation in 
most vegetables and some animals, show this suspension from the 
same cause, and its restoration in both with the return of spring. 
Mosses and animalculse have been deprived of all appearance of 
life, on being dried, and kept apparently dead as specimens in cabi- 

2 



10 PRELIMINARY OBSERVATIONS. 

nets of natural history for years, and then moistened into life and 
activity. 

It would be extending these remarks to an unreasonable length, 
were we to enter into a detail of all the analogies existing in these two 
classes ; the classical work of Good on the Study of Nature, and the 
more elaborate and scientific production of Carpenter, may be con- 
sulted for further information on this subject* 

What are the natural inferences from the analogy thus found to 
exist throughout the two classes of organized matter ? — An analogy 
in some instances so close, as to amount to identity of action, ren- 
dering it difficult to know whether to consider some genera of 
plants as animals, partaking, as they do, so much the nature of both, 
as to have received a name indicating their mutual identity. It is 
clear that the property which causes the phenomena of life is the 
same in both, and an inherent part of the organization for deve- 
loping the structure and sustaining it against its natural tendency to 
decomposition, a distinguishing mark of one of the great kingdoms 
of nature ; and that a derangement of this essential property, either 
directly or indirectly induced, must produce disease. 

As it appears that vitality is no special controlling agent, a dis- 
tinct power or essence apart from organization, but a law of its na- 
ture, or that plan for its continued action which the Creator has 
originally given to it, and which is essential to its existence, so it 
might be expected that vitality would be found as an inherent pro- 
perty in every tissue, organ and fluid, constituting the organized 
structure. 

That vitality is inherent in the tissues, or in a set of organs, 
appears from various experiments that have been made on ani- 
mals, and particularly on the muscular fibre, proving it to be inde- 
pendent of the peculiar action of any other part ; and it is also 
proved by the analogous action in vegetables. 

In animals, until the time of Haller, the nervous system was be- 
lieved to regulate all the functions of the body, including, of course, 
the contractile power of the muscles, the actions of which were 
divided into voluntary and involuntary, a distinction long since 
made by Willis, Boerhaave, and others ; the first mentioned class 
taking their power from the cerebellum, while the latter were re- 
ferred to the cerebellum. 



* Principles of General and Comparative Physiology, by William B. Carpen- 
ter, London, 1839. 



PRELIMINARY OBSERVATIONS. 11 

The experiments of Haller led him to the belief that there ex- 
isted in the muscles a property independent of the nervous power, 
the vis insita or contractility, by which it yielded to the influence 
of appropriate stimuli : the involuntary muscles to the stimuli of 
the blood, alimentary substances, etc., and the voluntary muscles 
to the stimulus of the nervous power, the exciting or suspending 
of which was the source of action or rest in these muscles. The 
existence of a power independent of the cerebro-spinal system, has 
been repeatedly proved by the experiments of dividing the nerves 
going to the muscles, and then stimulating them to contraction ; 
this contraction has also taken place after the limb has been re- 
moved from the body. 

In recent experiments, Dr. Philip* has proved that the muscular 
action of the heart, and vessels which carry on the circulation, 
even in the remotest parts, arise from an inherent power indepen- 
dent of the nervous system, and that the circulation in the capil- 
laries is itself independent. In the muscles of voluntary power, 
the nervous influence, so far from bestowing excitability, exhausts 
it, like other stimulants. The muscular power of the stomach and 
intestines, also, like that of the heart and blood vessels, resides in 
themselves ; and they consequently act from their own power, when 
deprived of the nervous influence. The vessels of secretion, also, 
have no necessary dependence on the nervous system ; and al- 
though the nervous power occasionally influences them, yet these, 
as well as those of circulation, possess an intrinsic vitality, manifest- 
ed by their own peculiar phenomena. 

These facts have a very remarkable analogy exhibited in the 
contractility of the fibrous tissue in vegetables ; a texture which 
Vauquelin has proved does not exist exlusively in animals, having 
been also discovered in plants, where no organs for the transmis- 
sion of nervous power has ever been found. This contractile power 
is very great in several plants ; the Venus fly-trap, Dioncea mu~ 
scipula, the sensitive plant, Mimosa sensitiva, and other highly irrita- 
ble vegetables, furnish remarkable instances, independent of any- 
thing like nervous power; for galvanism has been applied in vain to 
excite contraction of the vegetable fibre in these plants. The 
brain and nervous system in animals are manifestly organs of rela- 



* Ab Experimental Inquiry into the Laws of the Vital Functions, by A. P. W. 
Philip, M. D. ; Lond., 1839, pp, 43, 99, 103. 



12 PRELIMINARY OBSERVATIONS. 

tion, connecting them more perfectly with the surrounding world, 
and in the body being a medium of union between the various 
parts of the system, by which the mutual dependence of parts is 
made more subservient to the perfection of organization : they are 
not therefore to be regarded as the source of vitality, but simply 
as possessing a vitality of their own, with their own mode of its 
manifestation. 

If vitality be a property of organization, it must exist in every 
part of the organized body, in the fluids as well as the solids; and 
experiments prove its existence also in the fluids. The celebrated 
physiologist, John Hunter, has proved in a number of instances 
the life of the blood ; making it analogous to the muscles, in pos- 
sessing the property of contractility on the application of stimuli; 
this contractility or coagulability is greatly increased where vital 
action is much exalted, as in fever and inflammatory diseases. It 
retains also an equality of temperature in every degree of atmos- 
pheric cold, while circulating in the body ; and even in the state of 
the germ or ovum, as is seen in the young chick, it resists for a 
long time a great degree of cold and heat, and the process of de- 
composition. The blood, in limbs that have become paralytic, has 
the power of preserving life when the vital energy has departed 
from every part. It can, also, by its own inherent power, produce 
new vessels of every description from its own substance. The 
blood, also, like the muscular fibre, may by a stroke of lightning be 
in an instant deprived of its vital properties, and like the effect of 
the same agent on muscle, it may be left uncoagulated and uncon- 
tracted. 

Vital actions have been regarded by some, who have repudiated 
the idea of a controlling power or principle, as nothing more than 
certain movements of either particles or masses of matter, closely 
analogous to those in unorganized matter, denominated chemical 
or mechanical, and which are justly ascribed to the powers resi- 
dent in these matters causing the phenomena of attraction and 
repulsion ; similar powers and properties in organized structures 
being competent, while they are in mutual cooperation, to effect 
those actions in which life consists, and which of course terminate 
on the cessation of this cooperation, as the ingredients of a chemi- 
cal compound cease to be agitated when their affinities are satisfied * 



* Rudiments of Physiology, by John Fletcher, M. D., Edinb., 1837. Part V. 
p. 26. 



PRELIMINARY OBSERVATIONS. 13 

Such a view of it goes farther than the present state of science 
will warrant ; and all we at present know of it is, that this remark- 
able property, so essential to organization, can only be known 
by its effects. "We have seen that its manifestations and re- 
sults are exhibited with close analogy in vegetables and animals ; 
that upon its normal exercise depend growth, nourishment and 
preservation; and that the organization itself extends and multi- 
plies vitality, so that both life and organization are mutually 
dependent, the one of necessity existing with the other. A more 
perfect knowledge of its nature, in all probability, we will never 
possess ; and indeed in the present state of science, there is nothing 
more known of physical phenomena than their effects, which, 
from the similarity of their manifestations, their freedom from 
complication, the definite ideas we form of them from the simplicity 
of one physical property in many cases, make us contented with 
observing them in their results, and being satisfied with this amount 
of our knowledge in reference to them : those which are the 
product of vital action, being much more multiplied, from the great 
variety of the organs which exhibit them, so complicated from 
their connection with other parts, especially in animals, and, on 
these accounts, affording us less definite notions, as the results of 
one power, we naturally feel less satisfied with the knowledge we 
have of them. 

As the proper exercise of vitality is necessary to health, so any 
derangement of it must be productive of disease ; therefore it is 
not to be expected that structural alteration must in all cases pre- 
cede disordered function, as has been asserted by some ; a condition 
disproved by daily experience, all the phenomena of disease 
being often, except in the case of physical injury, nothing more, at 
the commencement, than the evidences of deranged action. 

That vitality may at once be affected independently of any pre- 
vious disorder of the organization, appears from a stroke of light- 
ning, or from the effects of prussic acid. It is also well known, 
that an attack of congestive scarlet fever will cause a great loss of 
vital energy, depriving the heart and blood vessels of their power 
to carry on the circulation, the patient steadily and rapidly parting 
with vitality, and quickly dying, without the slightest evidence of 
reaction. These are extreme cases, but are on that account re- 
markably illustrative of the derangement of vitality being a cause 
of disease and death. The spontaneous gangrene of a limb, 



14 PRELIMINARY OBSERVATIONS. 

which is its total death, is an instance of the effect of the loss of vi- 
tal energy in a distinct and separate portion of the body, showing, 
that as the vitality of the part is in the part itself, so, from a cause 
for which we cannot assign a reason, the cessation of this action 
will necessarily arrest the process of absorption and secretion, and 
terminate the sustenance of the part, abandoning it to the ope- 
ration of those chemical changes to which all animal substances na- 
turally tend, when not under the control of vitality. 

It is not from this cause alone that diseases may arise ; they may 
be produced by derangement of structure, as the primary move- 
ment affecting the life of the part, as is natural to suppose would 
be the case when the sustaining power is a property of organization. 
Contusions, wounds or fractures, are the most prominent instances 
of derangement of function from molecular disturbance : the vital- 
ity of the part being thus affected, becomes in its turn a cause of 
irregular action, thus materially affecting the natural progress of 
nutrition, and the organization experiencing, and when sufficiently 
continued, exhibiting the effects of this morbid influence. 

Vitality and organization being therefore dependent on each 
other, whatever deranges the one must necessarily affect the other; 
each in its turn becoming successively the cause of disease, mani- 
fested by various phenomena exhibited according to the different 
organs or tissues affected, and the stage of the disease. Inflamma- 
tory action, structural alterations, all disordered action of whatever 
nature, must be referred in the commencement to the altered ac- 
tion of the inherent property referred to, produced either by a cause 
affecting it directly, or indirectly through the structure. 

If it be impossible for us to explain in what manner it exists, or 
what is the nature of its departure from the normal action in the 
production of disease, or to direct appropriate remedies for the 
prompt removal of the deranged action, we have no greater amount 
of ignorance in relation to this subject, than of the nature of mag- 
netism, and of the variation of the magnetic meridian, or of the 
means of correcting the deviation; and in the remedies for both 
aberrations, the analogy still exists, our efforts being rather to coun- 
teract by suitable means the effects of these changes, than to attempt 
to alter their real cause. This law applies to every department of 
natural science. 

The tissues or anatomical elements of the organs may be indivi- 
dually diseased, possessing as they do the property of vitality in 



PRELIMINARY OBSERVATIONS. 15 

themselves. The dermoid, osseous, exhalent, absorbent, cellular 
and raucous tissues, are those apparently more often diseased than 
others. The skin, from its complicated structure, and from the fa- 
cility of observing its changes, affords a familiar illustration of the 
independent affections to which a tissue is subject. In erythema- 
tic inflammation of slight character, the reticulated vascular tissue 
is the morbidly affected part, and the only symptom is a slight itch- 
ing, and as an ultimate effect, the separation of the cuticle in small 
scales. The sub-cutaneous cellular tissue may also become the seat 
of inflammation, producing tumefaction, exhalation of serum, or se- 
cretion of pus. The various forms of eruptive or exanthematous 
affections have their seat either in layers of the skin, or in the seba- 
ceous and mucous follicles. Whatever be the forms of the disease, 
they are the effects of a deranged, and generally an exaltation of 
the organic action of the part, and may occur independently of the 
action of any other tissue. 

From the intimate association of one organ and its functions with 
others, and from the harmony existing throughout the whole frame, 
a part of the animal system, however small it may be, can rarely be 
disordered, without producing a deranged action in other parts; no 
modification can occur without involving in its changes other or- 
gans and disordering their functions. These effects may arise from 
simple mechanical obstruction or contiguous sympathy, from the 
necessary dependence of the whole system on the proper exercise 
of the functions of the organs, and from the general sympathy ex- 
ercised by the organs on each other through the medium of the 
nervous system. This connection is more perfect in proportion to 
the high grade occupied by the animal ; in man, therefore, it exists 
in the highest state of perfection, and arises from the necessity of 
the actions of the functions to preserve life ; and when all the or- 
gans throughout the system act in harmony, a healthy activity is 
the result. 

It is obvious, therefore, from this mutual dependence, that when 
a disordered action occurs in one part, others will participate to a 
greater or less degree in the derangement, whether it be of func- 
tion or organization ; and when either are affected, the other will 
participate in the derangement. Respiration gives an instance of 
the influence of a function on the organization ; for if it be from 
any cause interrupted or suspended, and the venous blood be no 
longer changed by the oxygen of the air, every part instantly feels 



16 PRELIMINARY OBSERVATIONS* 

the effect, and of necessity dies; the brain, spinal marrow ant£ 
heart, all have their functions arrested, and circulation and conse- 
quently nutrition cease, from the defect of the supply of oxygenated 
blood to the tissues. Upon the integrity also of the digestive func- 
tion depends the healthy formation of the sanguineous fluid, and 
consequently the process of interstitial nutrition, and the proper 
action of the organization : disease must therefore ensue where so 
important a function is deranged. When the organization is affected, 
also, as in the case of injury to the respiratory muscles, or to the 
portion of nervous system supplying them with the nervous influ- 
ence, respiration is necessarily affected. 

The connection of parts from sympathy may be illustrated in 
irritation of the mucous membrane of the stomach and bowels ; 
from undigested or acid ingesta, exciting a similar action, or even 
one of greater severity, in the brain : convulsions in children not 
unfrequently arising from this cause, without the existence of any 
morbid state of the structure; all the symptoms being speedily re- 
moved upon the evacuation of the irritating cause. It is also 
worthy of remark, that sympathy exists in a greater degree where 
vitality is in the greatest exercise; children consequently mani- 
fest it in a very marked manner, and in acute diseases, it is also more 
perfectly developed than in health. 

From this sketch, vitality is evidently a property peculiar to the 
organized structure, and as such, its actions are traceable through 
all living things, from the lowest cryptogamic plant to the highest 
part of the scale of animal life, as an independent property of the 
anatomical elements, possessing throughout an identity which proves 
it to belong to the remote part of organization where nutrition oc- 
curs, and on which the growth and preservation of the body de- 
pend Its manifestations by different phenomena in the different 
organs and fluids, from which the solids are formed, are presump- 
tive evidences of its inherent, independent nature in each tissue, 
corroborated by the analogy of the lower animals and vegetables, 
where separate portions possess the power of separate existence 
as distinct individuals. The healthy action of each part and of all 
parts, therefore, depends altogether on the integrity of this proper- 
ty; for without its agency all parts must suffer, and disease and dis- 
organization be the result ; being essential to health, wherever it 
is in any degree affected, disease of greater or less severity must 
follow. 



PRELIMINARY OBSERVATIONS. 17 

In the adult, the whole operations of vitality may be comprised 
in the preserving and recuperative processes ; to them are added, in 
the infant and child, the more active process of developement, with 
all the train of consequences upon its disturbance in any one part 
or tissue. In the child every thing predominates that is connected 
with organic growth, and of necessity with a redundance of vi- 
tality; and on which alone the growth of the body depends. The 
desire for food is frequent, the digestion rapid, the blood and all the 
fluids are in great excess; capillary action, secretion, deposition, 
and interstitial increase, proceed with great vigour, while the ner- 
vous sensibility is in the highest activity. In all parts of the body, 
therefore, when growing, vitality is in the most powerful exercise; 
and from all the phenomena attendant on growth, the latter differs 
from inflammatory action only in degree, a condition which may 
speedily be induced upon any disturbance of the developing pro- 
cess. In the various ways in which vital action may be deranged, 
whether it be by being suddenly attacked independently of the or- 
ganization to which it belongs, or secondarily through a disturbance 
of the minute tissue of the structure, how important does it appear 
to the growing- child, and how fraught with danger to its existence, 
where this property of the structure is interrupted in its energetic 
action. 

It has been remarked that infants grow more during the first 
year, the increase becoming less rapid as the child approaches the 
fourth or fifth year; and it is well known that during the first men- 
tioned period, violent disease and sudden mortality more frequently 
occur than at any other time of life. Here then is a direct relation 
subsisting between the rapid increase of the body, and its tendency 
to severe, sudden and fatal disease : the naturally exalted action 
of the capillaries in developing a part, being easily made to pass the 
boundaries of the healthy process of growth, and become the active 
agents of inflammation. The obstruction also of one part, and the 
continued developement of another, may give a preponderance to an 
organ or set of organs, which, although not so violent and fatal as the 
instance just cited, may yet impart a peculiarity to the body mate- 
rially affecting the health through after days. 

The symptoms accompanying the process of dentition, are a fa- 
miliar illustration of the influence of the developement of apart in 
producing diseased action. Although a natural and healthy pro- 
cess, yet it is almost always accompanied with an increased flow of 

3 



18 PRELIMINARY OBSERVATIONS. 

blood to the gums and salivary glands, the former become swelled, 
and the latter are excited to increased activity. In the greatest 
number of instances, stomatitis to a greater or less degree occurs, 
and the mouth appears hot and dry, and febrile disturbance not un- 
frequently attends this process; and these derangements are re- 
markable in proportion to the number of teeth growing at once. 
Another instance of the effect of developement of parts is the dis- 
proportion between the rapidity of the eruption of the teeth and the 
growth of the jaw : the tardy developement of the latter uniformly 
occasioning inflammation. The connection between teething and 
disease is one of great importance in the treatment of children du- 
ring that period ; for whatever morbid phenomena may arise, this 
process invariably adds to the existing excitement, from the great 
susceptibility of the system at this time. Acute diseases, or simple 
nervous disturbance, may often be speedily alleviated by removing 
the irritation of the gums; and a knowledge of the fact of the great 
derangement produced by the irritation of the protruding teeth, has 
long enabled the physician to bring a most powerful remedial means 
to the relief of children suffering from disease during the develope- 
ment of the teeth. 

The influence of growth has also been remarked in the effect of 
the pits left in early life after small-pox, whereby the excretory 
ducts of the skin, of which there are many millions, are obliterated. 
At the early period of life a serious change occurs in some of the 
most important functions of the animal economy ; for the integrity 
of the circulation on the surface of the body, which is a very essen- 
tial process in early life, is materially affected. To this have been 
referred the diseases of the glands, eyes, eyelids, bones, and other 
organs, which have been observed to follow small-pox, and to con- 
tinue, with remarkable obstinacy, until age has in some respect 
restored the circulation to its proper balance.* 

Another illustration of the effect of the developement of parts in 
the production of disease, is that afforded by the muciparous folli- 
cles of the intestines. Before the period of dentition they are 
scarcely to be discerned, even on the closest inspection. When in 
the order of the natural unfolding of the various parts of the infant's 
frame, those parts which are about to be fitted to the reception of 
a new kind of food are undergoing the necessary changes, these 



* T. Chevalier, Lond. Med. and Phys. Jour., August, 1828. 



PRELIMINARY OBSERVATIONS. 19 

follicles for the first time show themselves in a state of activity, 
pouring forth an abundance of their peculiar secretion. Thus far 
their action is a natural one, and one of health. Should it become 
excessive, a serous diarrhoea is the consequence, demanding the in- 
terference of the physician for its removal. This same condition 
of developement of the follicles, when complicated with other de- 
rangements of the system, and kept in a state of morbid activity by 
the continual operation of certain exciting causes, terminates by 
producing one of the most fatal diseases of our climate, the cholera 
of infants. 

The developement of the brain also gives another instance of the 
deranged vital action, at a time when this action is in the greatest 
excess, causing disease. It is well known that this organ, although 
large in size, is very imperfect at the time of birth, consisting mere- 
ly of a mass almost fluid. It is not complete in its parts until a 
year or more has elapsed, during which period the vital energy of 
the part is in great activity, carrying on the process of develope- 
ment. Is it therefore a matter of surprise that infants are so often 
attacked with convulsions, on the application of any cause which 
will in any way disorder the all-important action of building up the 
great source of supply of the stimulus to the muscles ? — irregular and 
involuntary contraction taking the place of the ordinary effect of a 
healthy condition of the brain and the regular transmission of ner- 
vous power. 

Besides these particular evidences of the effects of developement, 
there are others in which an excess of action in one set of organs 
gives a preponderance of one system over another, and imparts to 
the child a peculiarity which predisposes it to a certain class of 
diseases. Thus, where the circulating system is active and vigorous, 
every thing shows great strength, the body receiving a full supply 
of blood ; nutrition proceeds with great activity, and a strong ten- 
dency to inflammatory diseases exists, where this developement, or 
sanguine temperament, occurs. 

Other children are seen with a sluggish circulation, little activity 
of the muscular system, and presenting the appearance of greater 
developement and preponderance of the lymphatic system; and 
congestions of these organs, and obstructions of the mesenteric 
glands, are the affections to which such are subject. 

It can therefore scarcely be questioned, that parts undergoing 
developement, from the necessity of active nutrition during that 



20 PRELIMINARY OBSERVATIONS. 

process, are exposed to greater danger than those which have 
attained their proper maturity ; and as we have seen that the pre- 
disposition to disease is evident in particular organs, which give 
unequivocal proof of their liability to derangement during growth, 
so we may naturally conclude that all parts, when growing, are 
more exposed to the action of th3 great variety of exciting causes 
of disease. Where the active agent of developement is in full ex- 
ercise, any interruption in one part, by disturbing the equilibrium 
of the process, will produce an inflammation or congestion, either in 
the part itself, or in the contiguous structure from which it receives 
its supply of fluids. The derangement will be in proportion to 
the healthy organic action of the part, if the principle in physiology 
be correct, that an organ is disordered in proportion to its previous 
activity. Vigorous circulation in the organs, and an abundant sup- 
ply of blood vessels in the tissues, render children extremely liable 
to sudden inflammatory affections, rapid in their progress, and too 
often fatal in their termination ; effusion quickly following an acute 
attack of disease, of serum in serous membranes, as the arachnoid, 
or of lymph in the mucous membranes, as in the trachea. 

The extreme excitability of the nervous system, from the excess 
of vitality, also will cause .a sympathetic irritation in other organs, 
which themselves become proportionally disordered, from their 
own naturally exalted action at this period of life. This strong 
disposition to sympathetic disorder is a peculiar source of danger ; 
for, however slight or unimportant the original or primary affection 
may have been, the complication induced in an organ, on whose 
normal action the well-being of the child depends, becomes the 
cause of serious and fatal symptoms; the degree of danger often 
depending on the importance of the parts complicated in the 
disease. 

Thus it appears that the excess of vitality dependent on devel- 
opement, is the source to which the great frequency of diseases in 
children is to be traced, and from the same cause, rendered far 
more dangerous by the sympathetic participation of other organs. 
Their diseases are for the most part sudden, and the participation 
of other parts, especially the brain and its membranes, no less 
sudden and ( severe: the disordered affection soon passing through 
its course, and if its acute action continue, terminating in effusion 
and death. 

The practical deductions from the suggestions and facts here set 



PRELIMINARY OBSERVATIONS. 21 

forth, are, first, to meet the disease of children in their invasion 
with promptness and decision, whatever be the remedial means 
resolved on ; and secondly, never, under the most discouraging 
circumstances, to consider any case as hopeless. 

Much valuable time may be lost by a temporizing method ; such 
a course, if even ever admissible, can be so only when the acute 
symptoms have disappeared. Perhaps the physician is called too 
late to take the case under his care with energetic and active treat- 
ment ; indeed, the symptoms even of severe affections may be ob- 
scure, and the oppression of the circulation impart a languor and 
feebleness to the frame when important organs are affected, not 
only giving the parents no suspicion of danger, and thus causing 
delay in the employment of proper remedial means, but also not 
unfrequently being a source of embarrassment to the physician in 
his diagnosis. But when the disease is seen in its commencement, 
and especially if it be strongly marked with inflammatory or con- 
gestive symptoms, decided measures should at once be adopted, 
and the disease, if possible, be at once cut off; for upon measures 
promptly and judiciously used at the commencement, the life of 
the child may altogether depend. These may often be followed 
with singular benefit by such remedies as will tranquilize the mor- 
bid excitement of the nervous system, administered according to 
the prevailing symptoms, and the nature of the affection, and thus 
prevent the lighting up of disordered affections in other organs. 
It is not intended here to specify either diseases or their remedies, 
but simply to suggest the general principles on which the diseases 
of children are best managed, depending, as they do for their pro- 
duction, on the important agency of a superabundance of vitality ; 
views which are fully borne out in practice, the only true test of 
the correctness of any theory. 

In the second place, from the powerful activity of all parts en- 
gaged in supplying, developing and repairing the structure, when 
once the violence of the disease is removed, the physician should 
never abandon the child, however hopeless the case may appear to 
be. Where vitality is in so great activity, the powers of the system 
are adequate to almost any reparation, and are often exhibited to 
an extent, and under circumstances of depression, which will leave 
him without excuse who would regard any case as beyond the 
reach of remedies. It is true these instances do not make their 
appeal to us so much by their numbers, as by the evidence they 



22 PRELIMINARY OBSERVATIONS. 

give of the strong inherent power of the body to resist destruction 
at the commencement of life, and thereby afford a powerful induce- 
ment for increased endeavours to add to the numbers already in- 
creased five fold in the space of three centuries. Since the natural 
tendency of the body at this early period is — not to die, but to 
live — to increase— to unfold itself, and by successive developements 
to become by degrees fitted to the high station in animal and in- 
tellectual life for which it was destined, how does it behoove those 
who have assumed the important charge of its preservation, to use 
all the efforts which enlightened science affords, to assist the natural 
inherent powers of the system in resisting any tendency to disso- 
lution, at a period of existence when dissolution is in reality an 
unnatural process of the structure. 

With the knowledge of these facts before us, and of the pro- 
gress already made in the nature and seat of disordered affections 
— with the still greater insight into the mysteries of other depart- 
ments of physical science which has been attained, and the control 
which this knowledge has enabled us to exercise over some of the 
most powerful agents in nature, is it too much to hope that the 
bright beams of science, still dispelling the clouds which obscure the 
operations of the organic kingdom, may exhibit to our view the 
nature of the secret actions which give to living bodies the powers 
they possess, and thereby enable us also promptly to control their 
actions and to arrest their aberrations, and to restore to their wonted 
energy the deranged and disordered functions, on which the integ- 
rity of the structure and the life of the individual depend? 



TREATISE 

ON THE 

DISEASESOF CHILDREN. 



VITAL FUNCTIONS. 



RESPIRATORY SYSTEM. 

PHYSIOLOGICAL PECULIARITIES. 

The respiratory organs consist of the nasal fossae, larynx, 
trachea, lungs and its membrane, together with the thorax; 
on the movements of which the act of respiration depends. 

The air passage through the nose varies in children in its 
form but little from that of the adult, and its comparative size 
is about the same. It differs in this respect from the passage 
to the lungs formed by the larynx and trachea, which is much 
smaller in proportion to the body. The larynx especially de- 
velopes itself much more slowly than other parts, and conse- 
quently does not acquire its full form for some years. Another 
remarkable feature in the developement of the larynx is, that it is 
irregular in different children, not undergoing the same changes 
in all, so. that it is smaller in some subjects than in others who 
are even younger.* 

At the time of birth, the cartilages, bones and muscles of these 
parts are very small and flexible, and all the cartilaginous rings 
are distinct, as in the trachea of an adult. At this period it is 
not unusual to find the larynx and trachea filled with mucous 
secretion, apparently without the existence of disease, to so 
great an extent, as to interrupt, and even prevent entirely the 
function of respiration, producing in the new-born child 
complete asphyxia. 

The larynx, but more especially the glottis, remains of a 
very small size for a very long time, differing but little in a child 



* Manual of Gen. Descrip. and Pathol. Anat, by J. F. Meckel; translated by 
A. Sidney Doane, M. D. 



24 DISEASES OF CHILDREN 

of three years and one of twelve. This smallness of the size 
of the glottis, is the reason that affections of those parts that are 
attended with any tenaceous secretion, or tumelaction of the 
lining membrane, are so highly dangerous in children, for a 
complete closure of the opening may ensue even from slight 
causes. This condition occurs from the plastic exudation of 
croup, and in the cedematous state of the epiglottis; diseases 
remarkably fatal in young children. The different capacity 
of the opening, in some instances, may also be one of the causes 
of the frequent attacks of suffocating diseases in some infants, 
while others are for years quite exempt from affections of this 
nature. 

At the age of puberty, however, the difference is so great, 
that the glottis doubles in length and breadth in the course of 
a year ; hence the remarkable difference observed in diseases 
affecting these organs at an early time of life, and after the 
period of puberty, when there is an almost entire exemption 
from those symptoms which characterize these affections in 
young children. The bronchia3, also, during the period of 
childhood, are quite small, but enlarge at the same time that 
the larynx undergoes a change. 

The size of the thorax is proportionally smaller than any of 
the other cavities of the body during infancy ; but on account 
of the greater length of the cartilages of the ribs, in proportion 
to the osseous part, it possesses much more elasticity, and thus 
in a measure compensates for its deficiency in size. 

The lungs in the foetus are only a dense mass of organized 
substance, of a brownish colour, entirely different in appearance 
and texture from the lungs of a child after respiration has been 
established. These organs are of a bright rose colour, incli- 
ning to red in young infants ; in youth they are of a darker 
colour, but do not assume their permanent hue until about the 
age of twenty years, when they appear of the well known mar- 
bled colour of adult age. 

The functions of the lungs present the most remarkable 
changes of any occurring in the infant frame ; for when in a 
normal condition, they almost instantaneously perform their 
appropriate function on the application of their natural stimu- 
lant, thus changing at once the condition of the child from a 
parasitic to an independent state of existence. 

Respiration is carried on with great activity in an infant, 
amounting to thirty-five or forty inspirations in a minute ; those 
of the adult being about eighteen or twenty in the same period. 
Although this is stated to be about the number of inspirations, 
yet it is extremely difficult to ascertain the fact with much pre- 
cision ; for when the thorax is uncovered in order to observe 



RESPIRATORY SYSTEM. 25 

its movements, the exposure causes an immediate acceleration 
in the action of the respiratory muscles. Nothing, therefore, 
can be ascertained with any degree of satisfaction, when de- 
sirous to obtain information from this source, as to its indicating 
the violence of diseased action. When they are noisy, from 
any obstruction in the nasal passages, the respirations may be 
counted. 

A remarkable circumstance in the manner in which respi- 
ration is performed by an infant is, that the ribs alone are the 
chief agents : the diaphragm acting but little, the size of the 
abdominal viscera not permitting it easily to descend. In- 
fants, when sucking, breathe altogether through the nose ; when 
this is obstructed by tenaceous mucus, great difficulty is expe- 
rienced both in breathing and sucking. The nose is, therefore, 
at this period, an important appendage to the respiratory 
apparatus. 

Children at all ages, but especially during infancy, require a 
free supply of pure air, as is evident from the fact of the great 
number of deaths in large cities, and more especially in the 
crowded alleys, densely populated houses, and hospitals for 
young infants, or under any circumstances where there is an 
evident insalubrity of atmosphere. All animals, especially 
when young, have been known to suffer from this cause. In 
Paris twenty-five per cent, of the deaths are children under the 
age of two years, in London twenty-eight per cent., and in 
Philadelphia about thirty-three, and in New- York a trifle less. 

On percussion, the chest of a child is very sonorous, owing 
both to the small developement of the muscles covering the 
part, and to the free and active condition of the ultimate ter- 
mination of the bronchias ; and it is probably owing to the same 
cause that the respiration in children is much louder than that 
of adults ; and when a portion of the lungs is required to per- 
form more than its ordinary amount of functional power, from 
disease existing in its vicinity, a similar sound is heard by 
auscultation, and has for this reason been called puerile respi- 
ration. This remarkable condition of a child's lungs exists 
until about the twelfth year, when respiration assumes the 
characters peculiar to it in the adult. 

On the establishment of respiration, the child cries, caused 
doubtless by the painful impression made by the cold air, for 
the first time applied to the surface of the body and lungs ; this 
feeling of excitement, or perhaps some degree of distress, 
appears from the rapid movements of its arms and legs. 

Physiologists have long attempted to account for the agency 
by which the first inspiration is effected. 

It was the opinion of Whytt, that the foetus received blood 

4 



26 ' DISEASES OF CHILDREN. 

already prepared for it by the mother, and that when this sup- 
ply ceased, an instinctive feeling, analogous to hunger, took 
place in the chest, by which the child naturally sought for air 
to supply the existing want. The brain excites the motion of 
the chest, thus preventing the fatal effects that would follow 
a quiescent state of the lungs. 

This appetite for air commences at birth, from the excited 
circulation arising from the struggles of the child ; a quantity 
of blood is thus sent through the lungs, and becomes the direct 
cause of the desire.* 

Haller ascribed it to the habit of opening the mouth while 
in the uterus, in swallowing the liquor amnii. When this mo- 
tion is repeated, on the child's being ushered into the world, 
the air finds its way in, and passes directly into the lungs ; 
blood is distributed through them on their expansion, and a 
continual supply of air is required to prevent the blood from 
stopping in its progress from the right to the left side of the 
heart. f Darwin adopts a like view of the subject in reference 
to the habit of moving the mouth in the uterus ; but this cannot, 
he thinks, be the sole cause of the first inspiration, for breathing 
and deglutition are different acts. The foetus, at birth, expe- 
riences an uneasy sensation from the want of air, for the relief 
of which, all the muscles of the body are thrown into action, 
and those of the thorax, together with others, by which the 
uneasiness is relieved.^ 

The French physiologist, Adelon, supposes that the succes- 
sive developement of the lungs and their appendages predispose 
them to the act of respiration.. As the lungs increase in size, 
and the pulmonary vessels enlarge, the ductus arteriosus be- 
comes less, whereby the lungs are prepared, on their being 
properly excited, to discharge their proper functions. The con- 
tractions of the uterus, also, prepare the foetus for the new 
change, by pressing the blood out of the placenta, and thus de- 
ranging the circulation. By this derangement in the distribution 
of the blood, an additional quantity of blood is sent to the lungs. 
A new impression is then made on the child by the action of 
the external air ; its coldness and weight make a painful sen- 
sation on the skin and other parts of the body. These impres- 
sions are conveyed to the brain, and reflected to the different 
parts of the muscular system, through the nerves ; the muscles 
of inspiration, as well as the others, receive this impression, 
transmitted by the nerves, whereby they are excited into 
contraction^ 



* Whytt on Vital Motions, sec. 9, p. 111. t Elements of Physiology, viii. 5, 2. 
t Zoonomia, rl, sec. 16. § Physiologie de l'Homme, p. 20. 



RESPIRATORY SYSTEM. 27 

The views of Dr. Philip are, that the muscles of inspiration 
are altogether under the control of the will, and are brought 
into action by the uneasy feeling which the foetus experiences 
on being separated from the mother, analogous to the first act of 
deglutition ; both acts arising from the will, and producing the 
contraction of certain muscles for the relief of unpleasant sen- 
sations.* 

Dr. Bostock's opinion is, that it is entirely of a mechanical 
nature, arising from the elasticity of the parts, from the re- 
moval of the pressure to which the body was subjected while 
in the womb : the expansion of the trunk depending merely on 
the removal of this pressure.f This latter view of the subject 
appears to be the nearest to the truth, although we still are in 
want of data whereby to explain satisfactorily the reasons of 
the changes which the lungs experience at birth. 

The cry of an infant demands some notice, as it not unfre- 
quently affords some indications of disease : it should therefore 
be the duty of the physician to become acquainted with the 
natural cry of an infant. The division of the cry made by Bil- 
lard, is one which is considered by all as founded in the philo- 
sophy of nature, and of great practical use. 

His division of the cry is into the cry proper, and the inter- 
val, or reprise. The former is produced by expiration, while 
the latter is the sound formed by inspiration, and appears to be 
caused by the sound of the air passing through the glottis in 
order to -reach the lungs. 

The reprise is heard but little in a young infant, and increases 
in intensity as the child advances in age ; it is the predomina- 
ting sound heard after a child has been exhausted by crying, and 
known by the name of sobbing. 

The crying of a young infant is unconnected with the shed- 
ding of tears. The secretion of tears is remarkably dependent 
on the mental emotion arising from sorrow ; it would appear, 
therefore, that as the brain of a young child cannot combine 
ideas, its distress is altogether of a physical nature. 

Crying is not always an expression of severe pain, but often 
of some uneasiness and instinctive want, arising from the posi- 
tion of the body, uncomfortable arrangement of clothes, or 
hunger and thirst. This may be known by the cries occurring 
at intervals, and also by being easily calmed. 

The peculiarity of voice in childhood appears to be connect- 
ed with the cartilaginous condition of the larynx, and the cry 
or natural language is caused by that tube alone, without the 

* Wilson Philip, M. D., in the Quarterly Journal, vol. xiv. p. 100. 

t Elementary System of Physiology, by John Bostock, M. D., vol. ii. p. 31, 



28 DISEASES OF CHILDREN. 

assistance of the organs of articulation. Although there are 
changes occurring in the larynx during childhood, yet there is 
nothing very appreciable until the period of puberty : at this 
time a change occurs in every part; the opening of the glottis be- 
comes larger, and the cartilages and muscles of speech increase 
in size. These changes are observed to occur in the male, in 
whom an alteration of voice takes place ; in the female but lit- 
tle change occurs, and the voice continues without much al- 
teration. 

The thymus gland is an organ composed of distinct lobes, 
situated at the upper anterior part of the thorax of the foetus ; it 
lessens in size after birth, and entirely disappears about the 
twelfth year. From a continued enlargement of this body after 
birth, it becomes a cause of some distressing and fatal affec- 
tions in infancy, arising from the obstruction to the breathing 
which it produces. 



SIGNS OF DISEASE FROM THE RESPIRATORY SYSTEM. 

Crying being the first and most common expression of distress 
in a child, the peculiarities arising during this act naturally at- 
tract our first notice ; and by a close and watchful attention, the 
cry of a child may enable us to make some kind of diagnosis of 
its diseases. 

When crying is remarkable for its strength and obstinacy, 
and especially if accompanied by an expression of distress in the 
face, with pallidness, it is a sign of the existence of severe pain, 
arising from protracted disease. 

It is sometimes sudden, and accompanied by an accelerated 
movement of the respiratory organs ; it is then an evidence of a 
violent and sharp pang, as that arising from the pricking of a 
pin, or a sudden paroxysm of pain: this occurs in peritonitis 
and spasmodic affections of the bowels. This sudden crying, or 
screaming, sometimes becomes protracted, when it indicates the 
presence of local inflammation, or continued pain from the pres- 
sure of the teeth on the gums. It is broken up into short 
paroxysms when the respiratory organs are the seat of the in- 
flammation, from the severe pain which is produced by the act 
itself. 

In prolonged disease the cry will not be continued through- 
out, but will falter, and have a dying sound at its close. This kind 
of cry is found in diseases of a very serious nature, as gelati- 
nous softening of the stomach, chronic pneumonia, inflammation 
of the brain and pericardium. In severe pain there is an acute- 
ness in the cry, both in inspiration and expiration. From its 



RESPIRATORY SYSTEM. 29 

occurring in the active stage of hydrocephalus, M. Manuoir, of 
Geneva, has denominated such a cry hydrencephalique, and re- 
gards it as peculiar to that disease : it will, however, mark the 
existence of any severe pain. 

The cry may sometimes be interrupted or intermittent, cha- 
racterizing affections of the larynx, and is caused by spasmodic 
affections of the muscles of the voice. This sound is peculiar to 
croup. The sound on inspiration is that which is distinctly heard, 
while the other is lost. The alteration in the tone, which is 
something between a cry and a cough, imparts to it a crowing 
sound, and is produced by a sudden intermittent movement of 
the larynx. 

This acuteness of tone produced by inspiration, occurs also 
in inflammation of the mouth, propagated to the tonsils and la- 
rynx, and may be regarded as a distinctive sign of inflammation 
in the trachea or larynx. 

When the sound of the voice is husky, it is a sign of catarrhal 
affections, and arises from the thick mucus obstructing the 
bronchia?, and preventing the air from circulating freely through 
the tubes in its passage to the glottis. 

The imperfect cry gives a moaning sound at times, and in 
new-born infants is a sign of extreme debility; the child using 
no muscular effort. Under such circumstances, and when 
following much inflammation, it is almost a certain precursor of 
death. 

Moaning is also an unfavourable indication, when it occurs 
with sudden stupor, after violent excitement, accompanied by 
screaming; these, together with sighing, and a drawling and 
nasal sound, indicate cerebral affection, bordering on effusion. 
When it is simply an indication of pain in the bowels, and ac- 
companied with a drawing up of the lower limbs, so common in 
spasmodic affections of the stomach and bowels, it is not to be 
regarded as indicating any thing serious. 

Fretfulness is in general a sign of simple uneasiness, and if 
long continued, denotes the invasion of some disease, and should, 
on this account, never be overlooked, as the successful treat- 
ment of infantile disease often depends on the early stage at 
which the proper remedies are used. It becomes important, 
therefore, when accompanied by other indications of disease. 

The voice in older children gives the same indication of dis- 
ease as in adults, being shrill in spasmodic affections of the la- 
rynx, as in Millar's asthma. Hoarseness occurs in catarrhs, in- 
flammations, and thickening of the mucous membrane of the 
larynx, and often remains for life, after an attack of croup or 
measles. 

Hiccup is produced by a sudden expansion of the thorax, 



80 DISEASES OF CHILDREN. 

and narrowing of the glottis, from a spasm of all the muscles 
of inspiration. In children the cause usually lies in the intes- 
tinal canal ; it may also arise from an affection of the nervous 
system, and especially in cerebral diseases. It often exists, with- 
out being a dangerous symptom, in irritations of the stomach 
or intestines, from any cause ; but should there have been any 
inflammation of the intestinal canal or peritoneum, the prognosis 
is unfavourable. 

Sneezing is a sign of an inordinate stimulation of the mucous 
membrane of the nasal cavities, and in children is usually an 
evidence of a local inflammation in these parts ; it may occur 
in irritations of the intestinal canal, from worms and other 
causes. 

Cough indicates a general disease of the respiratory organs, 
either idiopathic, from disease of the larynx, trachea, bronchia?, 
lungs or muscles of respiration ; or it may be sympathetic of 
irritation in the bowels, either from saburra or worms ; a very 
common cause of coughs in children. Sometimes great anx- 
iety precedes the cough, as in hooping-cough, when the ner- 
vus vagus is affected. A single short cough denotes pleuritis ; 
on the contrary, a paroxysm of coughing comes on in catarrh 
with profuse secretion, and in hooping-cough. 

In intermittent cough there is great nervous irritation, with 
or without organic changes of the organs ; it is chiefly observed 
in croup and hooping-cough. 

A constant cough is a sign of inflammation of the larynx, 
bronchise, or lungs. 

A harsh tone in the cough is a sign of catarrh ; a barking 
tone, of croup. A whizzing tone, without harshness, is an evi- 
dence of catarrh of the bronchial mucous membrane, before 
the secretion, which characterizes this affection, has appeared. 
The sound of the cough in hooping-cough is distinguished by 
its loud shrieking character. 

A dry cough appears at the commencement of catarrhs and 
inflammations of the respiratory organs, and is of short dura- 
tion when the inflammation is seated in the mucous membrane, 
and continues longer in pneumonia, and other serious affections 
of the lungs. 

When respiration is rare, the cause exists in the debility of 
the muscles of respiration, as is frequently seen in infants that 
are premature, or that are born feeble. If it is at the same 
time quick, it is an evidence of pleuritis, or of great debility 
occurring after violent exertion, in pneumonia, chronic bronchial 
catarrh, or effusion into the cavity of the pleura. 

The species of respiration which is performed by the upper 
part of the chest, indicates very serious disorders of the thoracic 



RESPIRATORY SYSTEM. 31 

viscera, as it is in proportion to the difficulty of ordinary respi- 
ration. That kind which has been called cervical, is performed 
by the exertions of the muscles of the head and neck, and is an 
evidence of the highest grade of difficult respiration in diseases 
of the lungs. Cephalic respiration is of common occurrence 
in pulmonary diseases of children, and is known by the mouth 
and nose moving violently in expiration and inspiration. The 
latter gives a very unfavourable prognosis. 

Inspiration is very difficult in diseases of the larynx, oedema 
of the glottis, or in any affections of this part, constituting 
what has been called Millar's asthma, and in most cases of 
croup, and causes the peculiar sound of these diseases. Expi- 
ration, on the contrary, is the most difficult part in diseases of 
the bronchia?. 

In chronic diseases of the lungs, a form which not unfre- 
quently occurs in children in that peculiarity denominated lob- 
ular inflammation, there is a gradually increasing dyspnoea, which 
is an unfavourable sign. Regular respiration is a favourable phe- 
nomenon, while irregular respiration is connected with a state 
of extreme debility from cerebral affections. If this amount 
to cessation in breathing, it is then intermitting, and is very 
unfavourable in cerebral affections and pneumonia. 

In healthy respiration, inspiration is of longer duration than 
expiration ; but in cases where inspiration causes great pain, 
as in pleuritis and peritonitis, it is cut short, and the relation is 
inverted. Inspiration is performed with great difficulty in 
diseases of the larynx, oedema of the glottis, inflammation of the 
epiglottis, and in most cases of croup. 

In healthy respiration, no sound is perceptible by the ear re- 
moved from the chest. It becomes sibilous in laryngitis, oede- 
ma of the glottis, and in croup. When it produces a sighing 
sound, the cause is generally in a congested state of the lungs, or 
debility of the respiratory muscles ; when it occurs in diseases 
of the brain, and acute hydrocephalus, it is an unfavourable 
sign. 

When it is necessary to obtain still more correct results by 
means of auscultation, the method practised in adults will be 
applicable to children, taking into account the age, sex, and 
temperament of the patient, 

The respiratory murmur is very remarkable in every part of 
the chest in children, and therefore does not become a sign of 
diseased action, as in adults. 

Diminished intensity of the respiratory murmur shows that 
there exists inflammation of the small bronchial ramifications, or 
obstructions in them from mucus ; its entire absence, with 
bronchial respiration, shows the existence of pulmonary indu- 
ration or pleuritis. 



32 DISEASES OF CHILDREN. 

Auscultatory sounds, in general, do not vary from those de- 
scribed as existing in adults, and therefore need no further 
notice, than a reference to them in the monographs devoted to 
their consideration. The stethoscope is not so easily used as 
in the adult, on account of the continual motion of the child ; 
it is much easier to apply the ear to the chest. 

Percussion may be employed by elevating the child in the 
air with one hand, while the sound is obtained by the other. 
When the pleximiter is used, it will be advisable to employ 
two at the same time, that the sound at the diseased part may 
be compared with that of the unaffected portion. The sono- 
rous nature of the chest in young children greatly favours 
the employment of percussion ; and in simple pneumonia there 
is either a complete dulness, or so evident an obscurity in 
some parts, as to contrast very strongly with the clearness of 
sound in another. Those most experienced in the examination 
of children by this method, prefer the direct application of the 
fingers to the intervention of a pleximiter. 



DISEASES OF THE RESPIRATORY SYSTEM. 

ASPHYXIA. 

The literal meaning of the word asphyxia, is a deprivation of 
pulse, »Mis with the privative « ; although the term is restricted 
to the loss of the heart's action from one cause alone, that of 
interruption of respiration, or in the case of new-born children, 
to an entire absence of the exercise of this function. Pulsation 
may continue for a while after the birth of the child, without respi- 
ration ; yet, if this be not established, the child must soon die ; 
pulsation may also be entirely absent in the cord, and the child 
be apparently dead. The term asphyxia will be used as ap- 
plicable to all these conditions in which a child may be born, 
without living the extra-uterine or independent life, and thus 
include in its signification its original meaning. The condition 
of still-born children, therefore, from whatever cause, whether 
from oppression of the brain, or mechanical or other impediment 
to the establishment of respiration, will necessarily come under 
the title which forms the head of this article. 

Etiology. — The causes which produce the apparent death 
of new-born children, have generally been considered by au- 
thors in a very vague and unsatisfactory manner, if, indeed, 
they have been at all alluded to, except in so far as they have 
been the subjects of the immediate observation of our senses. 



RESPIRATORY SYSTEM. 33 

Professor Mende, of Gottingen,* has however thrown some light 
on this subject ; and from a careful examination of the cases 
which have come under his notice, made the three following di- 
visions of asphyxiated children. 

In the first class he includes every species arising directly 
from the condition of the whole nervous system of the foetus 
not yet being fully capable of receiving impressions; the 
child, consequently, occupies a much lower grade than is usual. 
In the second class he places those that arise solely from the 
brain, caused either by a sudden or protracted pressure. In 
the third, are comprised those cases which depend on the 
imperfect condition of certain organs, or on some diseased state 
in which they happen to be at the time of birth, without the ■ 
action of which, the nervous system cannot be excited to act. 
The organs of respiration and circulation are those which come 
under this class. 

According to this view of Mende, all causes of asphyxia can 
be arranged. In the first class are those children who are born 
feeble, from various causes affecting the mother during gesta- 
tion, and also from a constitutional debility entailed by the 
father. Extreme youth of the parents, debilitated constitutions, 
from whatever cause, induced either from sickness or habitual 
intemperance, bad nourishment of the mother, etc., all have 
their influence in causing an imperfect developement of the 
foetus, and thus producing a diseased condition, which, according 
to its degree, renders the child unsusceptible to external impres- 
sions. In this class of causes may also be placed a diseased 
or deficient placenta or umbilical cord. As these are requi- 
site to the proper nourishment of the foetus, so their healthy 
condition is essential to the well-being of the young animal. 
Its structure has been found changed, and a part ossified or in- 
durated; it has also been found preternaturally softened. Tu- 
mors and hydatids, also, have been seen growing in its sub- 
stance ;t these changes, although not affecting the life of the 
foetus, may yet, if extensive, very materially interfere with its 
nourishment. The umbilical cord may also become varicose, 
and even burst, greatly weakening the child, although it may 
not die. J It has also been found tied in knots,|[ which, if tight, 
must necessarily impede the flow of blood to the foetus, and 
thus deprive it of the necessary nourishment. 

From these and other causes children may be born in a state 
of feebleness, rendering them almost incapable of extra-uterine 



* Analekten ueber Kinderkrankheiten ; Stuttgard, 1834, Part I. p. 94. 
t Burns' Midwifery, p. 206. t Baudelocque, sec. 1084. 

!l Mauriceau, Cases 133—136. 
5 



34 DISEASES OF CHILDREN. 

existence, without being necessarily affected with any serious 
lesions, as has been proved by post-mortem examinations.* 

A sudden detachment of the placenta, with hemorrhage, is 
another cause of asphyxia in children, from depression of vital 
power; so, also, is premature delivery. This state occurs in 
almost all premature children, to a greater or less degree, and in 
mature children, where there is evidently a deficiency of vital 
energy, from disease or imperfect nutrition. 

The second class, or that depending on the brain, may be 
divided into those which occur before delivery, and such as 
occur during the birth of the child ; in both arising from strong 
compression of the brain. Apoplectic stupor may follow a 
tedious labour, where a continual pressure of the head occurs 
in the bones of the pelvis, or from the continued powerful ac- 
tion of the uterus, artificially induced by the use of ergot. 
The contractions of this organ acting principally on the pla- 
centa, still attached to its surface, force an inordinate quantity 
of blood into the body of the child, and it is protruded, bearing 
all the evidences of a general congestion, existing to such an 
extent as to clog and arrest the circulation. 

This apoplectic condition may also arise during birth, after 
protracted and severe labours, when the uterus, from exhaustion, 
suddenly ceases to act when the head is expelled, which may 
remain in this situation for some considerable time. Dr. Col- 
linsf states, that he has known several children to have been 
lost, where the action of the uterus was tardy after the expul- 
sion of the head ; and advises, in cases where the pains do not 
return in three or four minutes, to use gentle traction, especially 
where the child does not breathe. The encircling of the neck 
by the umbilical cord, may also be a cause of the same apo- 
plectic condition, and produce a state of asphyxia, which, if 
not speedily relieved, w T ill be fatal. Pressure on the head, 
from the use of instruments, will not unfrequently have the same 
effect, and the child will be born, to appearance dead, while the 
injury, and even a loss of the cerebral substance from the 
crochet and perforator, will not at once destroy life ; for chil- 
dren injured in this manner have cried loudly after delivery, 
and even lived for some days. Professor Mende and others 
have mentioned these facts. 

The effect of tedious labours, and of compression, especially 
of the umbilical cord, are often evident in children who are 
born to all appearance dead, without any pulsation in the funis, 



* Billard on Diseases' of Infants ; Amer. edit., p. 59. 

t Practical Treatise on Midwifery, &c, containing the result of 16,654 births 
in the Dublin Lying-in Hospital, p. 5 ; London, 1836. 



.RESPIRATORY SYSTEM. 35 

but not in a state of apoplectic stupor : such instances almost 
invariably occur in breech and footling cases, especially in the 
first parturition. 

The too early application of the ligature on the cord, will 
also sometimes cause an embarrassment of the respiration, 
with the usual appearances of a disordered circulation, some- 
times to an alarming extent. 

The third class includes all species of asphyxia, from any 
obstruction to the passage of air to the lungs, or debility of the 
respiratory muscles. Congenital malformations of the thorax, 
trachea, or lungs, which prevent a free expansion of the organs, 
must interfere materially with respiration, and in some in- 
stances prevent it altogether. Malformations of the lungs 
themselves are rare, and must of course interrupt respiration 
to a greater or less extent ; the congenital congestion of these 
organs, and their hepatization, will also prevent respiration, and 
cause the death, of the child, either immediately or a short time 
after birth. In connection with a congested state of the air- 
passages, is that condition, arising apparently from a slight de- 
gree of inflammatory action, which has been observed on dis- 
section, where the existence of a quantity of mucus obstructs 
the passage of the air, and very materially impedes the re- 
spiratory function. 

Another cause has been stated as hindering the establishment 
of respiration, but which can scarcely occur, except from great 
carelessness or ignorance : it is that of the unruptured state of 
the enveloping membranes, by which the child remains entirely 
covered for some time after birth ; the air being altogether 
prevented from coming in contact with the organs of respira- 
tion, the child must of necessity perish. 

Semeiology. — Children are sometimes born in a state of com- 
plete and universal feebleness, produced by the causes first 
mentioned, and are unable to perform the respiratory functions 
except by short inspirations or sobs, followed by sighs at con- 
siderable intervals. This state will continue for a long time, 
the intervals becoming longer, and the inspirations less deep, 
until the child at length sinks from mere debility. On other 
occasions, especially where suitable measures are adopted to 
foster the little remains of vitality, the respiration will be gra- 
dually improved, and the full exercise of the function establish- 
ed. Symptoms similar to these will occur in cases of malfor- 
mation of the thoracic parietes, or hepatization of the lungs ; 
the respiration being impeded in proportion to the degree of 
these affections. In other instances, children are born without 
any evidences of life, the whole body being in a state of flac- 
cidity, and the cord destitute of pulsation. ' The surface of the 



36 DISEASES OF CHILDREN. 

body is pale and without circulation, and the whole appearance 
of the child indicates the almost, if not entire, abandonment of 
vitality. 

When the child is born in an apoplectic state, from any of the 
causes above mentioned, the face appears bloated and purple, 
and the surface of the body red, but retaining its ordinary 
warmth ; no difficulty can exist in detecting the cause of the 
absence of respiration in such cases, differing as it does so 
evidently from other conditions. In addition to these symp- 
toms, the cord still beats with its usual strength. 

The most common condition in asphyxiated children, is that 
which occurs without any turgescence of the face, or any other 
evidences of cerebral congestion, but with the existence of a 
slight strangulation in the efforts to breathe, clearly pointing out 
the existence of mucus in the air-passages as a cause of this em- 
barrassment. When no efforts are made to breathe, the body is 
then pale and lifeless, while pulsation continues in the Cord. 

Pathology. — The pathology of this affection is evident from 
the causes which have been detailed. In cases arising from 
mere debility, or imperfect nutrition, or immaturity of the child, 
great emaciation, or extreme smallness will be the condition of 
the body, as will very naturally be expected. 

In those instances arising from apoplexy, sanguineous conges- 
tion of the brain and spinal marrow is found to exist, by which 
the nervous power destined to stimulate the muscles to action 
is arrested. Effusions of blood have also been discovered 
beneath the arachnoid membrane, rarely in the ventricles, ac- 
cording to the experience of Cruvielheir, who has examined 
several of these cases.* 

Congestion or hepatization of the lungs, also, is not an unusual 
condition on which the defect or absence of the respiratory 
function immediately depends. This sanguineous congestion 
being a common occurrence in young infants, a slight excess 
of it would very easily obliterate, to a considerable degree, the 
air-passages. To this cause, also, is the mucus, so often found to 
embarrass the respiration of children, to be attributed; showing 
itself in a viscid tenacious state, or in that of a yellowish white 
matter, of the consistence of cream, in the bronchise.f 

Treatment. — When a child is born without breathing, the 
first means which should be resorted to for the purpose of es- 
tablishing respiration, is to ascertain if there exist any viscid 
mucus clogging the air-passages, and removing it if it be found 
there, by introducing the finger to the back part of the mouth, 
while the face is turned downward. If it adhere and abound 



* Anatomie Pathologique, vol. 5. plate 1. 
t Valleix, Traite des Enfans, p. 567. „ 



RESPIRATORY SYSTEM. 37 

in the fauces, the finger should be covered with a soft rag, and 
then being carefully applied to the back part of the mouth, the 
mucus should be disengaged. If these be ineffectual, and the 
non-establishment of respiration appear to depend entirely on 
the presence of this mucus, further efforts ought to be made, by 
elevating the lower part of the body, and gently striking the 
back between the shoulders with the hand. Attempts ought 
in all cases to be made, whatever be the cause of the want of 
respiration, to remove the thick mucus adhering to the fauces 
and larynx. 

When great feebleness exists, which is often but temporary, 
some stimulating substance may be applied to the mouth and 
nostrils, as brandy, hartshorn, etc. ; or the vapour of the former 
may be applied so as to stimulate the respiratory function into 
action, by rinsing the mouth of the accoucheur with it, and 
breathing into the mouth of the child. While pulsation con- 
tinues in the cord, it must by no means be divided, for we have 
still the foetal life to sustain the child, in the place of the inde- 
pendent life. During these efforts, while the face is exposed 
to the cold air, if the establishment of respiration be protracted, 
the body ought to be kept warm by means of warm flannel 
applied around it, as the loss of caloric will rapidly carry off 
the remnant of vitality. 

If the pulsation in the cord have ceased, it ought to be di- 
vided, and the child plunged suddenly in a hot bath, of the 
temperature of 100°; the momentary application of the stimu- 
lus of heat will often at once restore respiration. From the 
experiments of Dr. Edwards,* no advantage can arise from 
continuing the child in the bath, as the benefits are derived 
from the suddenness of the shock, and the stimulating influence 
thus communicated to the whole circulatory system. The 
body should be enveloped in warm dry flannel, and all unne- 
cessary fatigue ought carefully to be avoided. In cases of 
difficulty in the establishment of respiration, it not unfrequently 
happens that the same causes which at first prevented it, will 
continue to operate in a greater or less degree for some days, 
requiring constant attention; the circulation being excited by 
warmth and gentle frictions, while the child is kept perfectly at 
rest, and carefully nourished. Enemata of castor oil are also of 
great benefit, the languor of the system, and the cold and leaden 
colour of the extremities, being often very sensibly relieved 
after their use. 

In the case of asphyxia from congestion of the brain, the ab- 
straction of blood from the divided cord is the remedy which 
promises the only hope of success, as the resuscitation depends 

* On the Influence of Physical Agents on Life, p. 283. 



38 DISEASES OF CHILDREN. 

mostly on the removal of the congestion. This can very easi- 
ly be effected, by simply dividing the cord while pulsation con- 
tinues. If, however, it should have ceased, efforts to procure 
blood may still be made, by immersing the end of the funis in 
warm water, or by surrounding it with a fold of flannel satu- 
rated with hot water, while the discharge of the blood is assist- 
ed by squeezing the cord with the fingers. Although bleeding 
in this manner has its foundation in reason, corroborated by the 
experience of most practitioners, Baudelocque, Burns, Dewees, 
Eberle, etc., yet it has found objectors, from the fact, that the 
death of the child has ensued after the use of this remedy ; an 
objection which would apply to every remedial measure, when- 
ever it was improperly used, or the condition of the patient 
placed him beyond the reach of any remedy. The livid and 
swollen appearance of the face proves the superabundance of 
blood, and that its abstraction is the only rational and effectual 
means for removing this preternatural fulness. As to the quan- 
tity which should be taken, this depends on the effect produced : 
no more should be drawn than is necessary to relieve the con- 
gested state of the brain. While these efforts are in operation, 
the proper measures should be adopted to restore directly the 
action of the respiratory functions ; a course which should, 
under all circumstances, be pursued. For this purpose, artificial 
respiration ought to be tried, by attempts to inflate the lungs. 

To effect this object, the nose of the infant being carefully 
closed, and a piece of folded muslin interposed between the 
mouth of the accoucheur and that of the child, the lungs should 
be inflated by gently breathing into them, while expiration is 
induced by compressing the thorax, in imitation of natural res- 
piration, while the head is extended slightly backward, to 
allow the air to pass more freely through the upper part 
of the larynx. This is all the inflation that is required; the 
use of a tube or bellows never being needed in the case of 
a still-born child. In experiments made on adult animals, life 
has speedily been destroyed by these mechanical means. Ar- 
tificial measures of this kind should, therefore, never be used, as 
a rupture of the air-cells might easily ensue. An instance of the 
effects of forcible insufflation is given by Dr. Eberle, occurring 
from the use of ordinary measures resorted to for the purpose of 
establishing respiration, which in this instance was not effected. 
A tumor appeared over one of the clavicles, which, on exami- 
nation, proved to have arisen from the rupture of the air-cells 
of a portion of the lungs ; the emphysema extending over a 
considerable portion of the surface of the pleura.* 



* A Treatise on the Diseases and Physical Education of Children, by John 
Eberle, M. D. ; Philad. 1837, p. 79. 



RESPIRATORY SYSTEM. 39 

The alternate dilatation of the chest by inflation and compres- 
sion, should be repeated at short intervals, until natural respi- 
ration has commenced. This is known by a deep, sudden catch, 
followed by a prolonged expiration or sigh, with a considerable 
interval between the respirations at first : the intervals gradu- 
ally becoming less, respiration at length assumes its regular 
action, the cry of the child first giving the evidence of its 
complete establishment, and is one of the best proofs we 
can have of the vigour of the infant. According, therefore, 
to the strength of the cry should we estimate the vigour of 
the child ; and if this be powerful, strong, perfect in both its 
parts, and well-sustained, we may, without fear as to the re- 
sult, direct the child to be washed and dressed, which, without 
these evidences of the strength of the child, have produced a 
fatal exhaustion. 

Upon the subject of tying the cord, there have been different 
opinions as to the proper time. Some have maintained that 
the pulsations in the funis should cease entirely before the ap- 
plication of the ligature ; while others have contended that it 
is only necessary for the child to breathe and cry vigorously, 
to admit of the tying and separating the cord. The former 
practice is undoubtedly the safest, although abundant expe- 
rience proves that but little hazard can arise where the respi- 
ration is fully established, although the pulsation may not have 
entirely ceased. For a long time after breathing has com- 
menced, pulsation will continue near the body of the child, 
while it will be found that it has entirely stopped near the pla- 
centa. An unnecessary delay may be avoided, by first ascer- 
taining the effect of compression on the cord between the fin- 
gers ; when the pulsation is found to be quite feeble, and easily 
arrested by the compression, without the appearance of any 
disorder in the circulation, the ligature may then be applied, 
and the cord divided with the most perfect safety. 

Where any malformation exists, it is obvious that but little 
can be effected by artificial means ; those already detailed will 
be those most applicable, according to the prominent symp- 
tom, if the conformation of parts allows of any hope of success 
in the use of them. 

Under all circumstances, particular attention should be paid 
to the temperature, for from a disregard to this, numbers of in- 
fants have doubtless perished ; for next to respiration, the 
maintenance of a proper warmth is of absolute necessity to the 
preservation of the life of the young child. Between the tem- 
perature of the womb and that of the body, there exists a diffe- 
rence, never less than 30° ; the sudden effect of this change, 
like that from heat to cold, acts as a powerful stimulus to the 



40 DISEASES OF CHILDREN. 

circulation ; but when this effect is accomplished, no benefit can 
possibly arise from a continued or an occasional exposure to 
cold, but, on the contrary, decided injury must arise from the 
continual abstraction of heat, where the power of its production 
is but feeble, and where the degree is less than in adults. In- 
attention to keeping a sufficient supply of warmth, independently 
of any unnecessary exposure, has sometimes proved fatal in a 
few days, resisting all endeavours to remedy the condition of 
coldness and depression when this state has been discovered. 
A continual moaning and sighing, together with a shrunk and 
bluish appearance of the face, and a leaden colour of the hands, 
will point out, with unerring certainty, the condition of the child, 
and demands as close attention to preserve life as an imperfect* 
condition of the respiratory function. 

In those cases of labour where the body of the child is deliver- 
ed some time before the head, there is great danger of the 
child's being lost, from the continual compression of the cord, 
before there is an opportunity for the mouth to be exposed to 
the atmosphere. Dr. Bigelow # has shown that the life of the 
child, under such circumstances, can be saved, even if the size of 
the head and the resistance of the pelvis and soft parts render 
the delivery of the head by traction either difficult or hazardous, 
by forming a communication between the mouth and the at- 
mosphere, before the delivery of the head. The fingers should 
be introduced, so as to reach the mouth of the child ; when this 
is accomplished, the hand is to be raised from the throat of the 
child, making the ends of the fingers a fulcrum, and pushing 
the perinoeum backward, by which the air will be admitted as 
far as the chin. The middle fingers are then to be separated, 
and a free passage will thus be made to the mouth. If the 
mouth be situated too high to be reached with the fingers, or if, 
from great compression, it is found difficult to pass the fingers, 
Dr. Bigelow recommends the use of a flat tube, made of gum- 
elastic, or spiral wire covered with leather, about half an inch 
at its largest diameter, to sustain life during the retention of the 
head. He even thinks it practicable to inflate the lungs under 
these circumstances. 

BRONCHITIS. 

Bronchitis, or inflammation of the lining membrane of the 
bronchise, is of frequent occurrence in children at every age, 
varying from a slight degree of irritation with mucous secre- 
tion, to a severe phlegmasia of the mucous membrane. When 

* Amer. Jour, of the Med. Sciences, Aug. 1829. 



RESPIRATORY SYSTEM. 41 

slight, or attended with but little inflammation, but exhibiting a 
copious secretion of thin mucus, it is that form of bronchial 
disease known under the name of catarrh. As the term ca- 
tarrh implies simply the existence of inordinate secretion, and 
relates to the secretion only, without reference to the patholo- 
gical condition of the part, it will not here be considered as a 
distinct disease, but included in the description of bronchitis, 
of which it forms but a symptom. Any peculiarities, therefore, 
which bronchial catarrh assumes, on account of which it has 
been described as a distinct affection, will be considered under 
the present head. 

Etiology. — This disease is most apt to occur in cold, wet, 
and variable weather, during the spring and winter. Not only 
may the exposure to the atmospheric vicissitudes become a 
/ cause of bronchial inflammation, but cold applied to the sur- 
face of the body in any way, as damp clothing, accumulation 
of urine for a long time without changing, etc. Smoke, or irri- 
tating gases, may also excite an inflammatory action in the mu- 
cous membrane of the respiratory passages. Bronchitis also 
arises from the constitutional irritation attendant on teething, as 
other inflammatory diseases are excited by the same cause, ac- 
cording to the peculiar predisposition of the child ; an impor- 
tant practical fact, to be kept in view in the treatment of all af- 
fections of children. It may also occur on the disappearance 
of an eruptive disease, when it often becomes protracted and 
obstinate, resisting, for a long time, the measures adopted for its 
removal. 

Semeiology. — On the first appearance of the disease there 
is a chilliness of the surface of the body, which is soon follow- 
ed by a quick pulse and hot skin. Cough is usually present 
from the commencement, at first slight, increasing gradually in 
hoarseness, and as the disease advances, accompanied with pain, 
which in young children may be known by a violent cry. The 
cough, at the commencement, is unattended with any secretion 
of mucus ; but shortly after the invasion of the disease a free 
secretion of mucosity takes place, which increases in quantity 
until the complete transmission of air to the air-vesicles is pre- 
vented, and all the distressing symptoms of suffocation present 
themselves ; the countenance becomes anxious, and the prolabia 
livid : all of which are aggravated on placing the child in a re- 
cumbent position. The coughing is often attended with strang- 
ling, and paroxysms of threatening suffocation, until relief is 
obtained by vomiting. These symptoms are, towards the ter- 
mination of the disease, sometimes attended with convulsions 
or stupor. The disorder of the respiration accompanies the other 

6 



42 DISEASES OF CHILDREN 

symptoms in their march, and as the latter increase in intensity, 
becomes more oppressed and difficult. 

Percussion yields a clear sound in every part of the chest at 
first, but different portions become dull towards the termination 
of the disease. Auscultatory examination discovers the exist- 
ence of the mucous ronchus, and it may even be heard without 
applying the ear to the chest, or without, the intervention of the 
stethescope. The use of this instrument in severe cases can 
scarcely be dispensed with, if we are desirous of making a 
prognosis of the disease ; and if we discover its peculiar cha- 
racteristic, the mucous ronchus pervading the whole of the 
chest, and the inflammation occupying the bronchise of both 
lobes, great danger may be feared if much constitutional de- 
rangement also exist. If, on the other hand, it is discovered to 
be partial, our prognosis may, in general, with ordinary consti- 
tutional vigour on the part of the child, be favourable, although 
the paroxysms of coughing and difficulty of respiration may 
be severe and exhausting. 

In very young children bronchial catarrh may often arise 
without any evident cause, and will scarcely exhibit any other 
symptom than the mucous ronchus, or a short, noisy respiration, 
without any distinct sound, which may be so denominated. 
When it attacks young children, it will at times continue during 
the whole period of lactation ; on other occasions it will increase 
in intensity in a very insidious manner* attended at first with 
no evidence of pain or distress. As the affection in this form 
advances, the breathing attracts attention from its peculiar 
wheezing character, almost imperceptibly changing to dyspnoea, 
and attended with drowsiness. This laborious respiration 
occurs for the most part in paroxysms, leaving the child during 
the intervals free from any urgent symptom, if the quiet drow- 
siness which generally attends it is not regarded as such. This, 
however, is one of the most fatal signs, and this form of bron- 
chitis, when once it has made strides thus far onward, is scarcely 
to be arrested by remedial means. One peculiarity is, that 
cough, so distinctive in ordinary bronchitis, is not always pre- 
sent in this form, and therefore is no mark of the disease. The 
pulse, is extremely quick, while the skin is cool and moist. 

The variety of bronchitis known by the names of catarrh 
and catarrhal fever, have at times prevailed epidemically, and 
been exceedingly fatal to children. The symptoms are much 
the same as those of ordinary bronchitis, but with much greater 
depression at the commencement ; the coolness and languor, 
and contracted condition of the surface, often lasting a whole day 
before the febrile reaction is fully developed. The symptoms 
are described at length by Dr. Eberle. It appears to be a 



RESPIRATORY SYSTEM. 43 

secondary affection, connected with a great derangement of the 
secretions of the chylopoetic viscera : the liver being in a torpid 
condition, and the alvine evacuations either deficient in bile, 
or giving evidence of its absence altogether. The right hypo- 
chondriac region is tender on pressure, and evidently enlarged. 

Among other varieties of this disease is that described by 
the late Dr. Parrish, of Philadelphia, as the congestive catarrhal 
fever.* It commences in the usual manner observed in bron- 
chial inflammations, but without the febrile symptoms noticed 
in the ordinary bronchitis. The symptoms are those usually 
observed in all congestive fevers. The pulse is frequent, but 
gives no evidence of fulness and activity in the circulation. 
The skin is cold and pale, and free from any dryness. The 
primae viae partake also of the general torpor of the system, 
and the bowels are inactive ; but the discharges do not give 
evidence, as in the last mentioned variety, of any derangements 
in the hepatic system. The cough, like that of the ordinary 
form of bronchial affections, is at first dry, but becomes moist 
during the progress of the disease. The most marked symp- 
tom, however, is the dyspnoea of a violent and distressing cha- 
racter, which induced Dr. Parrish to regard it as a spasmodic 
affection, and to treat it as such. It is exceedingly fatal to 
young infants, seldom lasting more than two or three days, and 
is almost beyond the control of remedies ; the excessive local 
congestion, and the loss of vital power, of which this is an evi- 
dence, make the use of ordinary remedies of little avail. 

Morbid Anatomy and Pathology. — Autopsical examina- 
tions show the bronchial mucous membrane in a state of increased 
vascularity, as appears from the injection of the capillary vessels 
with blood ; it is often thickened, but seldom softened. On account 
of the obstructions in the bronchiae, the lungs do not collapse on 
opening the thorax. A thin but tenacious fluid fills the entire 
substance of the lungs. Mucus, more or less thick, is usually 
found in the ramifications of the bronchiae, sometimes mixed 
with purulent matter, similar to what is occasionally discharged 
from the mouth in very severe cases of the disease, that have 
been quickly fatal. In other instances some degree of hepati- 
zation has been found in the lungs, particularly at its lower pos- 
terior portion: apparently the first progress of the disease 
towards pneumonia. Tubercles have at times been found at 
the root of the bronchiae, and in the lungs. 

Treatment. — The treatment of acute bronchitis must be 
strictly antiphlogistic, and adapted to the urgency of the symp- 

* Observations on a Peculiar Complaint in Children. N. A. Med. and Surg. 
Jour., Vol. I. p. 24. 



44 DISEASES OF CHILDREN. 

toms. When called early, the disease may be removed by the 
administration of a little syrup of ipecacuanha, every ten or 
fifteen minutes, until vomiting is induced, followed by pedilu- 
vium. If there exist but little febrile action, and the disease is 
of a slight character, the chest may be rubbed with some stimu- 
lating application, and a warm emollient poultice afterwards 
applied. In using embrocations in inflammatory affections of 
the chest, ammonia, which is so commonly employed, made into 
a liniment, should be avoided, as the fumes arising from it will 
tend greatly to aggravate the existing inflammation. 

If the disease be not alleviated at once by these measures, no 
time should be lost in availing ourselves of the principal reme- 
dy in the management of active inflammation ; and blood should 
be taken from the arm of the child, until an effect is decidedly 
manifested in the pulse. In robust children, bleeding by the 
lancet is indispensable when there exists much heat of skin and 
febrile action, or much difficulty in respiration. To be deci- 
dedly beneficial it ought to be employed early. If the eviden- 
ces of bronchial inflammation continue, leeches may be applied 
to the upper part of the chest, immediately under the clavicles. 
After bleeding, if but little febrile action follow, a blister should 
be applied over the chest, a means which ought not to be neg- 
lected in the treatment of bronchitis. It ought not to be left on 
until complete vessication has taken place, for in children the 
ulcerated surface left after a severe blister is often very diffiV 
cult to heal, and extensive sloughing has followed their use. 
If, however, the violence of the circulation has not been relieved, 
it would be well to attempt to allay the fever and dyspnoea by 
such remedies as relax the system. Nauseating substances, as 
ipecacuanha or tartar emetic, are used for this purpose ; and,, 
given in small and repeated doses, so as to act, also, as an 
emetic, will be found of great benefit in the treatment of this 
affection. 

Tartar emetic cannot be used without some hazard in young 
children, and I know of two deaths that occurred from poison- 
ing with this substance, in small doses given medicinally. 
Professor Hamilton, of Edinburgh, also mentions the occurrence 
of fatal effects from its use, but refers it to the child having 
taken the medicine on an empty stomach ; he therefore ad- 
vises, that the child be allowed to suck or drink before taking it. 
With this precaution, from one eighth to one sixteenth of a 
grain of tartar emetic may be given to a child from six months 
to a year old, every ten minutes, until vomiting ensue ; when 
there is evidence of gastric inflammation, its use should be avoid- 
ed. Vomiting is peculiarly serviceable in every stage of this 
disease ; and where there is much accumulation of mucus in the 



RESPIRATORY SYSTEM. 



45 



bronchiae, should be employed so as to act promptly, and thus 
relieve the tendency to congestion of the lungs, by removing 
the mucus which clogs the extreme branches of the air-passages. 
A very excellent combination is that so often used, composed 
of antimonial wine and syrup of squills ; # it is more useful where 
free secretion has taken place in the bronchias. Antimony, by 
itself, is more applicable to the first stage of the complaint, 
while the mucous membrane is in a state of inflammation. To 
quite young or new-born children, syrup of ipecacuanha is pre- 
ferable, as the dose may be exceeded without any unfavoura- 
ble effects following. A teaspoonful may be given to a child 
three or four months old, every ten minutes, until vomiting be 
excited, and half that quantity to one within the month. 

From the commencement of the disease, the bowels should 
be kept in a soluble state by the use of mild laxatives, but no 
advantage can arise from free purging. In robust children, a 
few grains of calomel, combined with rhubarb and ipecacuanha, 
may be given at first, and the bowels kept in an open state 
by the use of the annexed laxative prescriptions.f 

Where the secretion is slow in taking place in the inflamed 
membrane, and the violence of the disease, and the constitutional 
disturbance attendant on it, are in a measure allayed, expecto- 
rants will be indicated. Any of the nauseating articles may be 
used for this purpose. The efficacy of tartar emetic is greatly 
increased by its union with some alkali, probably from its facili- 
tating the absorption of the medicine.J But when there is a 
decided relief of the febrile symptoms, those of a more stimula- 
ting nature may be used, as the syrup of squills, in doses of ten 
or fifteen drops every two or three hours, to a child of two years. 
As its operation is by stimulating the capillaries, and thus exciting 
secretion in the diseased membrane, it is counter-indicated in the 
active form of the disease. It may be judiciously combined with 



* # Vin. Antim., 3ij. 

Syrup, Scillas, §iss. M. 
A teaspoonful every ten or fifteen mi- 
nutes, until vomiting ensue. 

# Pulv. Ipecac, 3j. 

Antim. Potass. Tart, gr. j. 
Oxymel. Scillee, 
Syrup. Simp., 
Aquae Font.,, aa. |ss. M. 
For children three or four years old, 
from one to two teaspoonsful. 

t Jfc Hvdrarg. Subm., gr. x. 

Pulv. Rhei, 3j. 

Pulv. Ipecac, g. j. 

Syrup. Simpl., §ss. M. 
One third is a dose for an infant. 



fy Mannse, 3 ss. 

Emulsio. G. Arab., |ss. 
Syrup. Violae, 3ij. 
Bene Admisce, et adde, 
Aquae, |j. 
From 3j. to 3ij. every three hours, until 
an effect be produced, for an infant. 
fy, 01. Ricini, §ss. 
Syrup. Rosse, ^ss. 
Vitel. Ovi, ran. 
Tinct. Sennse, 3iss. M. 
One to two teaspoonsful, for an infant, 
every hour. 

t R< Antim. Potass. Tart, gr. j. 

Sub. Carb. Potass., 3j. 

Syrup. Simpl., gij. M. 

A teaspoonful every two hours. 



46 



DISEASES OF CHILDREN. 



other articles which act also as expectorants, and thus obtain 
the combined influence of different remedies of the same nature, 
but acting in different modes.* 

In the last stages of the disease, when it has assumed a 
chronic character, more stimulating expectorants will be need- 
ed, and the senega snake root. (Polygala Senega,) so useful in 
croup, will be found of great efficacy. Some mucilage ought 
to be combined with it when it is given in decoction, in order 
to allay, in some measure, its acrid properties.! . I n very ad- 
vanced stages of this disease, and in its chronic form, when at- 
tended with much debility, it may become necessary to add 
some stimulant, to prevent the prostrating effects which some- 
times follow from its free action on the bowels.' Ammonia has 
been added for this purpose ; this, together with an anodyne, 
will sometimes be needed to meet bad cases of prostration. J 

Although, as a general rule, narcotics are to be avoided where 
it is necessary to keep up the secretions from the affected part, 
which is the indication throughout the whole period of bron- 
chial inflammation, yet it may at times become advisable to 
allay the violence of the cough, which is often so great in pro- 
tracted cases as greatly to distress the child, and deprive it of 
rest. A combination of Dover's powder with calomel and 
squills, will be found highly useful when an anodyne is need- 
ed,|| or either of the following mixtures, as the case appears to 
require ;§ and often the most salutary alterations will occur 
from the use of anodynes in long continued cases, by allaying 



* $ Vin. Antim,, 3ss. 

Oxymel. Sciilre, gss. 

Potass. Tart., 

Ext. Glycyrrh., aa 3j. 

Aquae, §j. M. 
One or two teaspoonsful, for an infant 
of twelve to eighteen months. 
# Oxymel. Scillse, 

Syrup. Ipecac, aa. gss. 

Succ. Glycyrrh., 3j. 

Mucil. G. Acaciee, gij. M. 
A teaspoon ful once in two hours, to a 
child of a year old. 
t IJ: Infus. Senegee, ^ij. 

Syrup. Scillse, §ss. 

Mucilag. G. Acaciee, fij. M. 
A teaspoonful once in two hours, to 
a child three years old. 

t fy Decoct. Polygalee, §jss. 

Carbonatis Ammoniee, gr. iij. 

Tinct. Cinnam., 

Syrupi Tolutani, aa. 3ij. 

Syrupi Papav., 3ij. M. 
3i.— 3ij. every second hour. 



(I fy Pulv. Doveri, gr. x. 

Hydr. Subm., gr. iij. 

Pulv. Scillee, gr. i., 

Sacchar. Alb., 3ij. 

Div. in pulv. No. vi. M. 
One to be given once in four or six 
hours, to a child of two years. 

§ fy Tinct. Cam ph. Opiat., §ss. 

Vin. Antimonii, 

Succ. Glycyrrh., 

Pulv. G. Acaciee, aa. 3ij. 

Aquee Fervent., §iv. M. 
A teaspoonful every two hours, to a 
child of six months. 

Jfc Vini Antimonii, 3j. 
Ext. Hyoscyam., g. iij. 
Syrup. Simpl., ^ij. M. 
A teaspoonful every two hours, to an 
infant from six to twelve months. 

fy Ext. Belladonee, g. j. 
Syrup. Ipecac, §j. M. 
From five to ten drops, to a child of a 
year old, in troublesome cough. 



RESPIRATORY SYSTEM. 47 

the morbid irritability to which children are so greatly subject, 
and allowing the powers of the system to rally from the wear- 
ing out of the nervous energy. When the skin becomes moist, 
they may be used with safety, care being taken to prevent the 
bowels from becoming constipated. The Sanguinaria Cana- 
densis has been extensively used in pulmonary affections ; be- 
ing an active stimulant, it is only useful in protracted cases, where 
the stimulation of the bronchial membrane becomes necessary 
to excite its secretion. In addition to these measures, the condi- 
tion of the gums should be examined, and if the teeth appear 
pressing on the gums, a free incision ought to be made ; and 
indeed it should be our duty, in the first place, to examine 
whether the irritation of teething be not the exciting cause ; for 
as was before remarked, where children are naturally predis- 
posed to bronchial affections, the constitutional disturbance 
arising at the period of dentition may be its sole cause. A 
great deal of useless treatment may be prevented by attention 
to this subject. After a child has for some time had a free 
discharge of saliva, under the irritation produced by the pres- 
sure of the teeth on the gums, the affections of the bronchise 
are very liable to make their appearance when it is arrested. If, 
therefore, the mouth be found dry, and the gums swollen, the 
gums over the protruding teeth ought to be freely divided. 

In those cases which occur in connection with the derange- 
ments of other organs, and which are dependent on them, the 
treatment must of course be directed to the removal of the 
primary cause of the disease. Affections of the liver, which, 
under some epidemic influence, ha preceded the bronchial 
disease, and on which it appears to depend, must receive our 
first attention. The object of the physician must be to restore 
the healthy action to the liver, by removing its congested state. 
A full dose of calomel will be required for this purpose, followed 
in a few hours by some laxative mixture. A free discharge of 
billious matter will be the best evidence of the relief of the con- 
gested liver. In cases exhibiting severe congestion, or inflam- 
mation of the pulmonary system, bleeding will be a necessary 
part of the treatment ; and in other respects the treatment need 
not differ from that adopted in cases of ordinary bronchitis. 

In the congestive catarrh, described by Dr. Parrish, a similar 
course of treatment will be needed, as the engorgement of the 
blood-vessels of the lungs constitutes the disease ; but as con- 
gestion is accompanied with great loss of vital energy of the sys- 
tem, and, indeed, as it is an evidence of this want of vital power, 
we should be cautious about abstracting blood, until some degree 
of reaction is produced by external stimulants. A large sina- 
pism ought to be placed over the chest, and the feet and legs 



48 DISEASES OF CHILDREN. 

immersed in a stimulating bath. If these means fail in pro- 
ducing reaction, the child ought to be immersed in a warm 
bath, rendered stimulating by the addition of salt ; blisters may 
then be applied to the legs, and on the appearance of a restora- 
tion of the circulation to its ordinary vigour, blood must be 
drawn as freely as the condition of the child will admit. 

The most important agent in the prevention of bronchial 
affections in young children, is the preservation of a uniform 
temperature ; for the changes in atmospheric heat is one of 
the most common causes of the complaint. A great deal has 
been formerly written on the advantages of early exposure to 
the changes of the air ; and even the practice has been urged, 
of daily immersing a young infant in cold water, for the pur- 
pose of hardening it, and enabling it to resist the deleterious 
influences produced by alterations of temperature : those indi- 
viduals who, from necessity, have been much exposed to atmos- 
pheric vicissitudes, having the power generally of resisting the 
effects of cold. But such practices are extremely reprehensible 
towards young children, and those who resist them prove 
thereby the robust vigour of their constitution. The power of 
producing animal heat, and, consequently, of resisting the effects 
of external cold, is different in all animals at different periods of 
life. When young, the natural instinct of all, teaches them to 
seek the genial warmth afforded by the mother, and her first 
desire is to impart it to her offspring. Mr. Hunter has proved 
that the young animal has less heat than the adult, and its power 
of evolving it much less ;* they must, therefore, be more liable 
to the baneful effects of cold. From experiments made by 
Edwards, in the Hopital des Enfans, at Paris, it is evident that 
the temperature of infants at the time of birth is at its mini- 
mum, and that it increases with the advance of age ; it is obvious, 
therefore, that they would be unable to bear the abstraction of 
heat with the same safety as adults at this early period. This 
important principle is borne out by some recent French statistics, 
which show a great mortality, during the cold winter months, 
among infants, who are taken out at a very early age, at all 
seasons, for the purpose of being baptized and registered. 

How important, therefore, does it appear to attend to these 
matters, as a preventive of the pulmonary affections of children, 
especially in a climate so variable as ours ! I am far from 
being an advocate of the opposite extreme of complete seclusion 
and undue tenderness, thereby destroying the stamina, and de- 
veloping a morbid susceptibility to external cold ; but would, on 



* Observations on certain parts of the Animal Economy, etc., by John Hunter, 
F. R. S. ; Lond., 1837, p. 134. 



RESPIRATORY SYSTEM. 49 

physiological principles, urge a strict attention to the subject, 
and the adoption of rational views in the prevention of disease 
in children. 

In proof of the beneficial effects of constantly maintaining 
an equable temperature in preventing bronchial inflammations, 
or, as they are usually termed, common colds, I would mention, 
that in those families where a temperature of a moderate degree 
is uniformly preserved throughout the winter, by means of hall 
stoves, I have had but few instances of these diseases to wit- 
ness, compared with those where such means of warming the 
house has not been in use. A remarkable and very unfounded 
prejudice exists in the minds of some on the subject of warming 
houses in this manner, not considering that it is far preferable 
to the warmth of a single apartment which is constantly ex- 
posed to the changes produced by the opening of the door, and 
that in a room warmed by means of an open fire-place, con- 
tinued streams of cold air are always passing from the crevices 
toward the fire, and children are thus exposed to the effects of 
cold. A fire, placed in a stove in the lower part of a house, 
will preserve a uniform temperature throughout every part ; 
and if all the doors in apartments are kept open, a vast mass of 
air will be thus warmed, which will not be liable to be changed 
in its temperature by the admission of air from without, as is 
the case in a small apartment, while a free circulation is main- 
tained throughout the house by the rarification produced by 
the stove in the lower part. 

PNEUMONIA. 

This disease is unnoticed by any other than modern writers 
as an affection of children. The ancients speak only of hooping- 
cough as a distinct affection, and confound all other pulmonary 
disorders under the general name of cough ; and even among 
many of our modern systematic writers it has not attracted 
the attention which its importance demands. Underwood 
passes it by almost unnoticed, simply mentioning it as connect- 
ed with pleurisy and pulmonary catarrh. Mr. Burns and Dr. 
Hamilton scarcely allude to this frequent and distressing dis- 
ease of childhood, except incidentally, when treating of catarrh 
and bronchitis. The more recent work of Evanson and Maun- 
sell contains scarcely a page on the subject ; that of Dr. 
Eberle has but little in relation to pneumonia, but some valuable 
remarks on its kindred affections, acute bronchitis and conges- 
tive catarrhal fever, while Dr. Dewees does not mention it at 
all. Although all these diseases have been considered as dis- 

7 



50 DISEASES OF CHILDREN. 

tinct, yet there was no attempt, until the essay of M. Duges, # 
to make any proper distinction between them. The articles of 
M. Guersent in the Diet, de Med., and the theses of MM. 
Leger-j- and Denis,J together with that of M. Brunet|| and Dr. 
Gerhard,§ and the extended remarks of Mr. Valleix, furnish 
the most valuable assistances in the proper diagnosis of the 
pulmonary affections of children. The paper of Dr. CumingH 
is exceedingly valuable on account of its judicious character, 
and the highly practical nature of his remarks on the treatment 
of this affection. The more recent work by MM. Rilliet and 
Barthez,** has supplied some important distinctions overlook- 
ed by other writers, in relation to the precise pathology of the 
disease, and in showing, also, the existence of the acute form of 
lobular disease, which had been unnoticed by others. 

From the investigations of the above mentioned pathologists, 
it is evident that pneumonia, in children of tender age, presents 
characters which differ greatly from the disease as it occurs 
in adults. These peculiarities will be noticed hereafter more 
particularly ; it is sufficient here to remark, that its characters 
are derived from the inflammation affecting the lobules. The 
period at which it assumes characters corresponding with a 
similar affection in adults, is fixed, by Dr. Gerhard and MM. 
Rilliet and Barthez, about the age of six years, seldom exhibit- 
ing the same anatomical peculiarities at an earlier period of 
life. The disease may attack children when in perfect health, 
or, what is of more frequent occurrence, makes its invasion in 
those that labour under some other affection, during the progress 
of which, an insidious form of pneumonia, with very obscure 
symptoms, often appears. Such cases have been denominated 
latent, and would often remain undiscovered without the aid 
of auscultation. The disease, therefore, naturally presents it- 
self under the forms of acute and chronic, or idiopathic and 
symptomatic pneumonia. 

Etiology. — Among the predisposing causes is age, which, 
from the little attention bestowed on the subject until within a 
few years, would scarcely be supposed to be, as it in truth is, 
the most frequent. Children between the ages of two and five 



* Recherches sur les Mai. les Plus Import, et les Moins Conn, des Enf. Nouveau 
n£s; Paris, 1821. 

t Essai sur la Pneumome, des Enf. j Paris, 1823. 

t Recherches Anat. et Physiolog. sur quelques Mai. des Enf. j Comercy., 1816. 

II Mem. sur la Pneum. Lobulaire., Journ. Hebdom., 1833. 

§ American Journal of Med. Sc, vols. xiii. xiv. 

IT Transactions of the Assoc, of Fellows and Licentiates of the King and 
Queen's College of Physicians, Ireland, vol. v. p. 28. 

** Mai. des Enfens. Affections de ^oitrine.. Prem. Part. Pneumonie : Paris, 
1838. 



RESPIRATORY SYSTEM. 51 

years, on post-mortem examinations, show a greater number of 
lesions o{ the pulmonary tissue than is to be found at any other 
age. In sixty cases of this disease, mentioned by MM. Ril- 
liet and Barthez, forty were between the ages above mention- 
ed, and twenty from six to fifteen. M. Hache, quoted by these 
authors, mentions that in one hundred and eight autopsies, he 
met pneumonic inflammation in seventy-one between the ages 
of two and five, and but thirty-seven from the latter age to fif- 
teen.* An hereditary tendency, also, is one of the usual pre- 
disposing causes, and ranks next to the early period of growth 
and developement. I have had frequent opportunities of no- 
ticing the great tendency to pulmonic inflammation in the chil- 
dren of some families. 

This disease, in its acute form, is more prevalent in the spring 
and winter ; in its chronic and complicated form, it is found to 
prevail more in the summer season. In many instances it can- 
not be traced to any well-ascertained cause ; but variations of 
temperature, even where they cannot positively be ascertained, 
are doubtless the most common agents in the developement of 
this disease, especially when combined with moisture. The 
acute variety may arise during the existence of some acute 
disease, as measles and other eruptive disorders. 

As to the chronic form, it makes its invasion in the youngest 
children in a very insidious manner, after an attack of some kind 
of eruptive fever; but generally after a chronic inflammation of 
the bowels. Almost any protracted affection, and the general de- 
rangement of the health from this continued irritation, as well 
as the excitement of the system during the process of dentition., 
may become a cause of chronic inflammation of the lungs. 
M. Billard regards the pneumonia occurring in young infants as 
caused by the state of the blood in their lungs : the blood un- 
der these circumstances becoming a foreign body, and produ- 
cing its effects by mechanical engorgement; and adduces, as one 
reason, the frequency of its occurrence on the right side, from 
the custom of the nurses in the Hospice des Enfans Trouves 
placing the children on that side when laying them down ;f but 
the frequent occurrence of inflammation of the lungs in the 
right lobe, in adults as well as in children, will not admit of 
this explanation being sustained. 

Semeiology. — The attack of acute pneumonia is for the most 
part preceded by symptoms of a slight catarrhal affection of in- 
definite duration, and other evidences of inflammation of the 
mucous membrane of the bronchiae, which, extending to the 



* Op. Cit. ; p. 77. t Op. Cit , p. 406. 



52 DISEASES OF CHILDREN. 

substance of the lungs, is soon followed by all the signs of a de- 
cided inflammation of the pulmonary tissue. When the disease 
is fully formed, there is no disease of infancy which presents a 
higher degree of fever than the one now under consideration. 
The skin becomes hot and dry, the pulse exceedingly active and 
full, beating from 120 to 160 times in a minute. The pulse, 
which at the commencement of the disease is generally hard 
and full, during its progress becomes very feeble, and towards 
the close almost imperceptible, and is one of the best means 
whereby a prognosis of the disease may be made. 

The cough is dry and painful, and performed with great 
effort, and is usually either preceded by a cry, or accompanied 
by some other evidence of pain. The frequency and fulness of 
the cough are good signs of the violence of the disease. When 
the former exists, with marked efforts to resist it, the disease is 
in proportion serious ; when, on the contrary, the cough is in- 
frequent and full, and performed without pain, there exists 
comparatively but slight affection of the lungs. In children, 
until the age of three to five years, cough usually precedes the 
other evidences of inflammation ; while in those that are older, 
this symptom shows itself simultaneously with others. The 
cough is sometimes entirely suspended towards the close of the 
disease ; a return of the cough, after it has for a time entirely 
ceased, is to be considered a symptom of convalescence. In 
some cases, the cough indicates the extension of the inflamma- 
tion to the trachea and larynx, and is known by the hoarse, ring- 
ing sound, peculiar to croup. Expectoration, it is well known, 
never occurs in infants at the breast; or rather, the expectorated 
matter, which is of a white colour, tough and stringy, is never 
ejected from the mouth except by vomiting. M. Valleix has 
noticed the discharge of a viscid froth from the mouth, slightly 
bloody, evidently from the bronchia?, for a similar product was 
found in these tubes on post-mortem examination. In older 
children, however, it takes place as in adults ; and a free dis- 
charge of mucus is a favourable symptom. 

The breathing, in acute pneumonia, is very much quickened 
above its natural standard, and may often be counted from 
sixty to eighty in a minute. Dr. Cuming even mentions, that 
in one case of a child of six months there were no fewer than 
one hundred and eighteen in a minute. The respirations may 
be intermittent, returning to the natural slowness for four or 
five respirations, and again becoming frequent, for about the 
same period. The respiration, as the disease advances, be- 
comes laborious, as is evident from the heaving of the chest, 
the anxious expression of the face, and the alternate contractions 
and dilation of the alae nasi. In some instances the lungs 



RESPIRATORY SYSTEM. 53 

appear to be so loaded with blood, as materially to obstruct 
the circulation of blood through them ; and if this congested 
state of the lungs be the most prominent symptom, and is not 
quickly removed, the jugulars swell, and the face assumes a 
livid hue, most remarkable in the lips and cheeks, while symp- 
toms of cerebral oppression show themselves. Under these 
circumstances the disease proceeds with great rapidity, the 
respiration becomes irregular, the child sighs and gape§, the 
circulation loses its force, the pulse becomes small and frequent, 
and the skin cold. Death ensues from the third to the tenth day 
after the attack. 

The favourable symptoms are, a diminution of all these 
symptoms of inflammation and congestion, and of the violent 
constitutional disturbance, such as restlessness and wakefulness, 
connected with them ; while the bronchial mucous membranes 
secrete freely, and the healthy action is restored to the skin, 
and the secretions generally show an abatement of the diseased 
action, and a return to the due performance of the functions of 
the system. 

The chronic form, which appears in children where the con- 
stitution is impaired by other diseases, is very insidious in its 
attack, and not unfrequently has proceeded to a fatal termina- ' 
tion, with scarcely a suspicion existing of its nature. At other 
times it shows itself by a short cough, at first dry, afterwards 
with the usual signs of a secretion in the bronchia?, and frequent 
respiration, varying from thirty-five to seventy in a minute. 
The face is partially flushed, and in severe cases, livid. In the 
generality of chronic cases, however, the skin is cool, face pale, 
and great emaciation exists, while the extremities are cedema- 
tous. 

In nearly all chronic cases there exists more or less derange- 
ment, of the digestive system, and diarrhoea is a very common 
attendant on this affection. Diarrhoea usually continues through- 
out the whole period of the disease, and consists of green 
liquid matters. The tongue is moist, and covered with a yellow 
fur in the most chronic cases ; such as approach more nearly 
to the acute form, the coating is whitish. Vomiting is of rare 
occurrence, except when induced by severe fits of coughing. 
The appetite generally is not impaired, but becomes so in 
proportion as the disease loses its chronic character, and where 
the dyspnoea is extreme, is almost gone. 

The physical signs of pneumonia are important in the diagnosis 
of the disease. In the peculiar form of the disease in young 
children, that in which the lobules are the seat, percussion, 
according to Mr. Valleix, is of little avail in detecting its exist- 



54 DISEASES OF CHILDREN. 

ence ; # Dr. Gerhard, on the other hand, asserts that percussion 
is frequently of more utility than auscultation, as a means of 
diagnosis in lobular pneumonia, f This discrepancy appears 
to arise from not sufficiently discriminating the different periods 
of the affection, for it is unquestionably true, that in the early 
periods of the disease, in its chronic state, when there is but 
little developement of the disease, and the inflammation is 
scattered over a large surface, with intervals of healthy lobules, 
but little or no alteration will be found in the sound of the 
chest on percussion. It is probably only useful when the lung 
has become indurated or hepatized to some extent, and it is to 
such cases that the remark of Dr. Gerhard applies, as would 
appear from the anatomical details of his cases. 

When the disease has arrived at the stage in which the 
change is appreciable by percussion, a dull sound will be heard, 
in proportion to the extent of the induration ; and when the in- 
duration occupies the greater part of the lung, the sound is 
decidedly flat. Nothing, therefore, can be expected to be 
derived from this method of examination, until a considerable 
change has taken place in the lungs. It is not so with com- 
mon lobar pneumonia, or simple pneumonia, as it is called by 
Valleix ; here obscurity of sound, varying to complete dulness, is 
perceptible in every part of the affected portion of the chest, 
strongly in contrast with the clearness of the healthy portion. 
This indication of disease often extends with surprising rapidity, 
and in a few hours, in acute pneumonia, will change its bound- 
aries to a great extent. None but such as have made the experi- 
ment can fully appreciate the important information which this 
fact conveys ; and the rapid progress of the disease thus 
proved, shows how valuable are the few hours at the com- 
mencement — opportunities for treatment never to be regained 
when once neglected. 

The peculiar form which infantile pneumonia assumes, will 
also often prevent the discovery of auscultatory phenomena early 
in the disease, when the affected lobules are widely scattered. 
But although, when there scarcely exists any rational symptom, 
the stethescope detects the presence of mucous or subcrepitant 
ronchus, at times mingled with dry ronchus : the subcrepitant 
ronchus often exists throughout the whole of the disease. 
Bronchial respiration is usually not developed until towards 
the termination, when the induration has extended to a con- 
siderable portion of the parenchyma. This remark, of course, 
applies to the slow, insidious form of pneumonia ; for in the * 
active form, as well as in lobar inflammation, bronchial respi- 

* Op. Cit., p. 135. t Amer. Jour., vol xv. p. 101. 



RESPIRATORY SYSTEM* 55 

ration is always found ; in the last mentioned, being heard over 
the entire lung, while in the former, when the case is ex- 
amined sufficiently early, in a portion of it, but rapidly extending. 
In those cases, indeed, where, from sudden and excessive con- 
gestion of the lungs, and the closure of the bronchise, the respi- 
ration ceases entirely in these tubes, bronchial respiration of 
course will not be heard. Although, therefore, percussion and 
auscultation are, together, the means of ascertaining the exist- 
ence of pneumonia, yet where the latter fails to procure the 
pathognomonic sign of the disease, other symptoms connected 
with the rapidity of its developement will come in to perfect 
the diagnosis. 

Pneumonia may be distinguished from pleurisy by the fol- 
lowing physical signs: The same dulness is observed on per- 
cussion; and although in both, extending widely with great 
rapidity, yet in the latter disease it is unattended with the 
excessive disturbance of the system noticed in the rapid ex- 
tension of pulmonary inflammation. While in both the dulness 
exists, in pleurisy there is nothing of the subcrepitant or mucous 
ronchus. The distinction between pneumonia and bronchitis 
is not difficult, if the symptoms already detailed are borne in 
mind. When the mucous or subcrepitant ronchus is heard in 
the latter disease, it is uniformly on both sides. This is the 
only auscultary sign that may cause these diseases to be con- 
founded. When it is heard at the lower portion of one lung, 
it is to be regarded as the commencement of pneumonia. 

Morbid Anatomy and Pathology. — One of the most re- 
markable distinctions between the inflammation of the lungs in 
adults and children, and which has already been alluded to, when 
speaking of the symptoms, is the affection of separate lobules, 
instead of a continuous inflammation of the entire pulmonary 
tissue, which characterizes the disease in the former. This is 
the form which the insidious invasion of the disease assumes, 
and which renders its detection often difficult, and without the 
aid of auscultation, in many cases impossible ; for on dissec- 
tion, small, distinct indurated portions will be found in the midst 
of lobules free from disease, or very slightly inflamed, while the 
patient, during life, presented but few distinctly marked symp- 
toms of pulmonary affection. This inflammation of the lobules 
is what characterizes the diseases of the lungs in infancy and 
early childhood, as it is never found after the age of five or six 
years. Young children, however, may be also affected with an 
inflammation of the lobes of the lungs in the same manner as 
adults are affected, but never, after the age above mentioned, 
has it been found to partake of the lobular form. While, 
therefore, autopsical examinations show that the partial, lobi#- 



56 DISEASES OF CHILDREN. 

lar, latent pneumonia ought to be regarded as a peculiarity of 
the disease in young children, they still have, at times, the true 
pneumonia of adult age, inflammation affecting the entire lobe : 
the former being, in a great number of cases, a chronic affection, 
and such as we might expect to meet with in debilitated sub- 
jects, and among those that are treated in public hospitals ; the 
latter occurring in those that are of a robust habit of body, at- 
tacked either during health, or while labouring under the influ- 
ence of some acute disease. 

The first stage of lobular pneumonia or induration, exhibits 
the cut surface of the lung of a marbled appearance of a gray- 
ish rose or red colour. These red spots are circumscribed to a 
greater or less degree, and are easily torn ; they float in wa- 
ter, and crepitate when pressed. 

The second stage is that which is usually met with on dis- 
section. The exterior of the lung is generally found quite soft, 
and of a gray colour, inclining to a rosy tint ; prominent cir- 
cumscribed spots have also been seen, of a firm consistency, 
and of a violet colour. These spots are usually circular, but 
occasionally vary from that form, and present an oval appear- 
ance from above downward; they are observed mostly in the 
posterior part of the lung, but have occasionally been found in 
other parts of the organ. The incised surface appears mot- 
tled with spots of a grayish rose colour, to a deep violet. The 
dark spots noticed on the external surface of the lungs penetrate 
the substance, and are, unquestionably, the result of inflammato- 
ry action ; and all the alterations of structure observed in different 
parts of the lungs, are from the same cause, differing in no 
respect from similar disordered action affecting the same tissue 
in adults. 

The third stage is that of suppuration. This condition, ac- 
cording to MM. Rilliet and Barthez, may easily be overlook- 
ed, as the colour of the lungs have returned to their natural 
state ; but some of the lobules will be found more prominent 
than the others, and on being cut and pressed, pus will be found 
to ooze from the surface. Abscesses have also been discovered 
in this form of pneumonia ; and cavities exist, from the size of a 
hemp seed to that of a pea, and in some instances communica- 
ting with the bronchise. 

These lobular inflammations may increase to a great num- 
ber, until the entire lung is affected, producing a complete alter- 
ation in the appearance of the lung, and which has been de- 
nominated by the authors just mentioned, lobular pneumonia 
generalized. 

Other alterations have been found in the lungs of young 
children, presenting, when cut, a number of granulation* of the 



RESPIRATORY SYSTEM. 57 

size of a millet seed, of a yellowish colour, containing a fluid 
of a purulent nature, which can be squeezed out when cut. 
Again it has been found shrunken, of a violet colour, with white 
lines marking the divisions of the lobules. The cut surfaces 
of the lung appear smooth and red, resembling muscle in their 
structure, and without crepitus on pressure. The violet colour 
shows that it differs from the hepatization of adults, while it 
bears a resemblance to the condition described by M. Louis, 
under the name of carnification, and has been so denominated 
by those who have investigated the pathology of children. 

All writers agree as to the frequency of double pneumonia in 
children, a circumstance of very rare occurrence in adults ; but 
like the disease in the latter, when it is confined to one lung, 
it is most usually the right lobe that is affected. 

The complication of pleurisy with pneumonia is very fre- 
quent in adults, but pleuro-pneumonia is very rare in young 
children. In one hundred and twenty-three cases which came 
under the notice of M. Valleix, pleurisy occurred only in twenty 
instances ; a fact which was before noticed by Dr. Gerhard in 
the paper already referred to. 

In young children, all their affections are more or less com- 
plicated, with evident derangements of the chylopoetic viscera ; 
and in the disease before us, lesions of the intestinal canal ex- 
ist, principally of a chronic inflammatory nature, as appears 
from the condition of the mucous membrane. 

Such is the amount of our knowledge on the subject of the 
pathology of pneumonia of young children ; important, inas- 
much as the frequently insidious progress of the disease — so 
slow and imperceptible as to have received the name of latent — 
might often put us off our guard until the affection has made a 
fatal progression. When the invasion is sudden and well-mark- 
ed, it will matter but little whether the disease be strictly lobular 
or lobar ; but as it is proved that the former affection is a 
peculiarity of young children, and that pathological anatomy 
has demonstrated the existence of a serious and fatal lesion 
formerly unsuspected, it will be our duty to ascertain, by the 
means which modern science has placed in our hands, the ex- 
istence or non-existence of such a form of disease in protracted 
cases of infantile affections, and by the timely discovery, to 
apply the appropriate remedies for its removal. 

As to the pathology of lobar inflammation, it differs in no re- 
spect from that of adult age. This, as was before remarked, 
may occur in children at every age, although some have been 
of opinion that it never appears until after the age of six years ; 
and M. Berton asserts, that it is not until the age of fifteen years 

8 



58 DISEASES OF CHILDREN. 

that pneumonia assumes all the pathological characters peculiar 
to the disease in adults.* 

Among the effects of inflammatory action in the lungs, is 
the infiltration of serosity in their tissue, forming a real oedema 
of the lungs. This condition is generally attended with very 
laborious respiration ; but in some cases extensive cedematous 
effusions have been found, without this condition having been 
manifested during life. Mr. Gardien mentions that it will be 
found without the presence of any antecedent lesion, and after 
symptoms which threaten immediate suffocation. But this 
generally is not the case, for it is usually complicated with 
bronchitis, pleurisy and pneumonia, and is evidently the re- 
sult of extensive inflammation in the various tissues and mem- 
branes of the lungs. 

Treatment. — In severe acute pneumonia, the success of the 
treatment mainly depends on the early period at which the 
treatment is commenced, and the promptness with which the 
proper remedies are applied ; and, although one of the most 
violent and serious affections which a physician has to encoun- 
ter, yet there is none more completely under his control than 
idiopathic pneumonia. A delay of twenty-four or forty-eight 
hours may place the patient entirely beyond the relief of reme- 
dies. The disease, as was before remarked, when considering 
its symptomatology, is astonishingly rapid in its progress, in- 
volving successive portions of the lungs in its influence, with a 
quickness, as revealed by percussion, which soon places it be- 
yond the control of art. It is therefore his duty to attack it at 
once, and extinguish it at its commencement. 

The first indication clearly is, to arrest the inflammation by 
the appropriate remedy of blood-letting, proportioned to the 
age and constitution of the child, and the violence of the inflam- 
matory symptoms of the disease. On the subject of general 
blood-letting in children, a difference of opinion has existed 
among physicians. Dr. Cuming,f Clutterbuck, J and others, are 
strong advocates for its use. Sydenham, also, observes that it 
may as safely be performed in children as in grown persons, 
and adds, that " it is so necessary in the peripneumonic fever 
above mentioned, and in some other disorders to which children 
are subject, that there is no curing them without it|| On the 
other hand, Professor Hamilton,§ of Edinburgh, Billard,^ and 



* Traits' des Malad. des Enfans, etc. par A. Berton ; Paris, 1837, p. 478. 
t Op. Git, p. 48. 

t Lect. on Blood-letting, repub. in Bell's Select Med. Lib. 
II Account of the Measles of the year 1670. 

§ Hints for the Treatment of the Principal Diseases of Infancy and Childhood, 
p. 84. 
TT Op. Cit., p. 269. 



RESPIRATORY SYSTEM. 59 

some others, principally French and German physicians, dis- 
approve of its use, and recommend leeches as a substitute. 
Dr. Hamilton objects, it would seem, to the loss of blood in 
any form in children. There exists in the minds of some a 
great dislike to the use of this remedy in children ; but believing 
that the fears so often entertained are in many instances 
groundless, I cannot too strongly urge its employment, where 
the attack is recent, and the child in the possession of ordinary 
vigour, having so repeatedly seen the immediate benefits of 
this course. Young children do not bear the repetition of 
venesection well, and when the further abstraction of blood is 
necessary, leeches must be applied to the axilla of the affected 
side. 

Immediately after the employment of blood-letting, a purga- 
tive will be found serviceable, both as a revulsive to the intes- 
tines, and for its agency in promoting the secretions from the 
liver and intestinal mucous membrane. There is no class of 
remedies, however, which appears to exercise so little influence 
on pneumonia, as purgatives ; they should, therefore, be regard- 
ed only as assistants to the general treatment, and used prin- 
cipally to remove the foecal accumulations, which are so apt to 
occur in febrile affection generally. The action of the purga- 
tive should be prompt and efficient ; for this purpose, calomel, 
combined with jalap and ipecacuanha, is what I have been in 
the habit of using. Jalap is an excellent adjunct to other pur- 
gatives in children, for its operation is not confined to any parti- 
cular portion of the intestinal tube ; a copious secretion usually 
follows its use, and when combined with ipecacuanha, as in the 
subjoined prescriptions, makes an excellent purgative powder 
for inflammation of the chest. To keep the bowels free, one 
or two grains of the same powder may be given every hour, 
to a child of a year old.* 

After the operation of the cathartic, if the lungs are still 
much oppressed, it will be proper to administer an emetic ; and 
antimonial emetics are, in general, used for that purpose, as their 
operation is beneficial, not only in relieving the loaded bron- 
chise of its secretion, but also in restoring the equilibrium of 
the circulation. Where antimony is deemed hazardous, from 
the tender age of the child, syrup of ipecacuanha may be sub- 
stituted, as recommended in the preceding article. The effect, 
however, of emetics, is not so beneficial in this disease as in 

* Ifc Subm. Hydr., gr. v. 

Pulv. Jalap, 3ss. 

Pulv. Ipecac, gr. v. 

Sacchar. Albi., gr. x. M. 
From 2 to 5 grains every third hour. 



60 DISEASES OF CHILDREN. 

simple bronchial inflammation, attended with a free secretion 
of mucus. Revulsives should by no means be neglected, but 
the feet and legs ought to be early immersed in a stimulating 
bath, especially when the violence of the inflammatory symp- 
toms are in some degree abated. 

During the continuance of the inflammation, diaphoretics 
should be constantly used, and any emetic substance acts in this 
manner when given in small doses ; these, and the expectorants 
recommended under the article on bronchitis, are applicable to 
the disease before us. 

When the violence of the inflammatory symptoms are in 
some degree removed, and the heat of the skin and fever are 
abated, while evidences of pulmonary congestion or irritation 
continue, blisters will often be found of great service, applied 
over the affected part. When secretion becomes free in the 
bronchi se, the treatment must be directed to the relief of the 
symptoms arising from excessive secretion in these tubes, by 
the use of emetics, which may be varied according to the cir- 
cumstances of the case ; the treatment differing but little from 
bronchitis, to which subject the reader is referred for the use 
of the different expectorants and emetics. 

The treatment of chronic pneumonia is based upon the same 
principles, which should direct us in the management of the 
acute form of the disease; all our efforts being directed to di- 
minishing the quantity of blood passing through the lungs. In 
general, blood-letting should be by leeches, or scarification and 
cups ; which latter method many practitioners prefer, on account 
of the facility of ascertaining the quantity of blood thus taken. 
After the abstraction of blood, if this is deemed necessary, as in 
some debilitated cases it might be deemed hazardous to have 
recourse even to the smallest quantity of bleeding, revulsives 
are the remedies principally to be relied on ; stimulating baths 
to the lower extremities, sinapisms to the chest and back. Dr. 
Gerhard mentions, that no bath is superior to the sulphur bath 
in chronic cases of pneumonia,* taking care that the child's face 
be not exposed to the vapors arising from it, and that he be re- 
moved before symptoms of exhaustion arise. The bowels 
should be kept open with mild laxatives ; and when the disease 
is connected with an inflammatory affection of the mucous 
membrane of the bowels, and protracted diarrhoea, the reme- 
dies recommended under that head must be associated with the 
treatment. When not counter-indicated by the presence of 

* # Potassa Sulphur, grij. 
Aquae, fc c. 

H. des Enfans. 



RESPIRATORY SYSTEM. 61 

other symptoms, the use of the more stimulating expectorants 
will be found necessary. . Coxe's hive syrup, the compound 
syrup of squills, in doses of five to ten drops every three or 
four hours, to a child two or three years, may be found useful 
for this purpose ; or where more stimulation is needed, the sub- 
joined prescription.* 

PLEURISY. 

Pleurisy is a disease of greater frequency in young children 
than is generally supposed, although occurring less often than 
either bronchitis or pneumonia ; owing probably to the fact 
that this membrane is less exposed to the immediate influence of 
the action of the atmosphere. MM. Rilliet and Barthez, on 
the contrary, say they have very rarely met with simple pleu- 
risy unconnected with other pulmonary inflammation, between 
the ages of two and five years. Although comparatively rare in 
young infants, it is found to occur as frequently in children from 
the age of three years and upwards as in adults, and with the 
same violence. In younger children, its appearance is usually 
insidious, its progress slow, and its character either sub-acute 
or chronic ; but violent acute pleurisy may occur at any age, 
as I have repeatedly seen, if any thing like diagnosis can be 
depended on. 

Etiology. — The causes of this affection are those in general 
which produce inflammatory diseases, of which cold, applied 
to the surface of the body, is the principal. As this has been 
already considered, and the inferences arising from it as to the 
prevention of disease, have already been alluded to under the 
article on bronchitis, it is unnecessary here to repeat them. 

Semeiology. — When acute, pleurisy commences with the 
usual symptoms of inflammation — chills, succeeded by febrile 
excitement. There is great restlessness, and evidently severe 
pain, as the constant crying of the child indicates. When 
the pain allows the cry to be free, it is heard clear and dis- 
tinct, without any other alteration, except such as arises from 
pain and exhaustion. In addition to restlessness, there exists 
great difficulty in the attempt to fill the chest ; and the dila- 
tation of the thorax is made with great pain, and accom- 
panied with marked contractions of the abdominal muscles. 

* fy Rad. Seneg., 3ss. 

Infus. in s. q. Aq. Ferv., 
per { hor. colatur, §iv. 
Adde, 

Ammonise Hydrochl., 3ss. 
Syrup, althsese, gj. 
A teaspoonful every hour, to an infant of six months. 



62 DISEASES OF CHILDREN. 

This distress is increased when the child lies on one side. Al- 
though at times disposed to cough, yet it is often arrested, from 
the pain attending the effort. As the disease advances, the 
difficulty of breathing increases ; the pulse loses its force ; the 
eyes appear sunken and livid ; the extremities cold and cede- 
matous, and a comatose state ensues before death takes place. 

The disease, however, is sometimes destitute of these strong- 
ly marked symptoms, and will make its advances with signs 
so obscure, as to render it difficult to detect its presence. The 
child, in the incipient stage, is for a time languishing and feeble, 
daily losing its flesh, and crying, as if suffering from some con- 
tinued distress, which increases on lying down. It will there- 
fore be necessary, from the obscurity of the rational symptoms, to 
ascertain, from the physical signs, the existence of this or some 
other pneumonic disease. It is extremely difficult, it has been 
asserted by Billard, Rilliet and Barthez, to ascertain precisely 
the presence of pleuritic inflammation, as both percussion and 
auscultation give very uncertain signs of the disease. Unless 
there also exists some degree of effusion, the physical signs 
are obscure ; they, however, consist of dulness on percussion, 
and the presence of bronchial respiration. The dulness affects 
the entire part of the side affected with the disease, while there 
is less violence in the symptoms than attends a similar extent 
of pneumonia. As the inflammation decreases in convales- 
cence, the subcrepitant ronchus is not heard, as in pneumonia. 

Morbid Anatomy and Pathology. — In acute pleurisy ad- 
hesions are found, which, in cases of short duration, are easily 
separated ; a condition entirely different from that which arises 
in protracted or chronic disease. Besides these, plastic exuda- 
tions between the pulmonary and costal pleurae, effusions of 
lymph, purulent matter, or sero-purulent fluid, are found in the 
pleural sac. The membrane itself is usually spotted with a 
number of red points. In chronic cases there exist more ex- 
tensive adhesions of a firmer character, with appearances of 
granulations, and evidently of a longer standing. 

Treatment. — On the first appearance of acute pleurisy, 
blood must be freely taken from the arm, and permitted to flow 
until a slight effect is evidently made on the circulation, known 
by the increasing softness of the pulse, and the paleness of the 
face. If the child be old enough to describe his feelings, the 
same rule should be observed as in treating the same disease 
in adults ; the pain should be evidently lessened. On the re- 
turn of fever, pain, and the usual accompaniments of inflam- 
mation, leeches ought to be applied to the affected side. When 
the constitutional symptoms are relieved, a blister may be advan- 
tageously applied, with the precautions already suggested on 



RESPIRATORY SYSTEM. 



63 



that subject. The bowels ought, also, to be opened, and kept in 
a soluble condition, by means of neutral salts, or the formula? 
mentioned in p. 45. 

Nitrate of potass has been recommended as a suitable re- 
frigerant and antiphlogistic, in pleurisy of children, as it so sen- 
sibly relieves the heat of the body, and diminishes the fre- 
quency of the pulse. But, although generally useful in adults, 
in delicate subjects it has been found to disorder the functions 
of digestion and assimilation ; it is, therefore, inadmissible in the 
case of young children, uncombined with some article to pre- 
vent its too irritating action on the mucous membrane of the sto- 
mach ; although Henke prescribes it in childhood, in all those 
diseases for which it is given in adults. Dover's powder is the 
best for modifying its influence, besides the advantage which 
may be derived from its controlling the circulation, and re- 
lieving the general irritability of the system. The subjoined 
formula is a form of combination,* which will be found very 
suitable for children, as there seldom exists a disease in them, 
without the presence of gastric derangement, or its superven- 
tion, during the progress of their diseases. 

In very robust children, where there is much difficulty in 
restoring the secretions generally, a combination of calomel, 
antimony and nitre, will be sometimes found advantageous.^ 

Where there exist symptoms of effusion, diuretics will be 
required, and acetate of potash is one peculiarly suitable for 
children, especially in chronic cases, as it possesses deobstruent 
qualities, and may thus assist in relieving visceral obstructions, 
which not unfrequently complicate their chronic affections. 

In cases of much irritability, digitalis is a powerful medicine 
for controlling tjj^e frequency of the pulse, influencing the capil- 
lary circulation, and increasing the urinary discharge. Its use 
is therefore indicated in inflammatory affections, attended with 
serous effusions. It may be given to children under a year, in 
the dose of one eighth to one fourth of a grain twice a day, or 
it may be administered in infusion, which is probably the best 
method of using it. J 

The medicine produces a feeling of nausea and languor, 
when the system is under its effects, and when excessive, blind- 



* Tfc. Potassae, Nit., gr. ij. 

Pulv. Ipecac, gr. \. 

Pulv. Doveri, g. j. 

Carb. Sodae, excic.,gr. j. M. 
To be given every two hours, in a lit- 
tle barley water. 



t ~fy Potassae, Nitr., gr. xx. 

Hydr. Subm., gr. j. 

Antim. Tart., gr. i. 

Of this, two or three grains may be 

given every second or third hour. 

X Fol. Digital, gr. viij. 

Aquae Ferv. giij. 
A teaspoonful may be given to a child 
from two to four years, every three hours. 



64 DISEASES OP CHILDREN. 

ness and vertigo succeed ; its operation, therefore, should be care- 
fully watched, and its use suspended for a while, until these 
untoward symptoms have disappeared. The best antidotes to 
an over-dose of digitalis are stimulants, a little weak brandy 
and water, or an infusion of serpentaria, while a blister is applied 
to the pit of the stomach. For the purpose of more fully di- 
recting its effects to the kidneys, a few drops of the syrup of 
squills may be added to each dose, and ten or fifteen drops of 
spirits of nitre may be given in the child's drink every three or 
four hours. 

The remarks generally on the subject of pneumonia and 
bronchitis are applicable to the disease now under consideration, 
except that but little advantage is to be derived from the 
employment of expectorants, as might be supposed from the seat 
of the affection. 

CORYZA. 

The flow of mucus from the nares, which is known by the 
names of coryza, gravedo, or snuffles, arises from an inflamma- 
tion of the mucous membrane lining the nasal fossae. It is, 
when protracted, a distressing disease in young infants, as it 
prevents their sucking ; respiration being in a great measure 
arrested, the child is compelled frequently to stop sucking in 
order to breathe. It appears under two forms, the simple, 
which may be either acute or chronic, and the malignant, as 
described by Drs. Denman and Underwood, agreeing with the 
pellicular, as it is termed by Billard. 

Etiology. — The ordinary cause of inflammation in the 
pituitary membrane, is that common to all inflammations of the 
respiratory organs, the application of cold t$ the surface of 
the body, either by improper exposure, or from negligence in 
not changing their clothes when wetted with urine. An- 
other cause, is the direct influence of the solar rays and light, 
when children are first taken out early in the spring for an 
airing, when unaccustomed to the effects of the sun ; hence the 
popular idea of the unhealthiness of the sun in the month of 
May, as young children are observed to sneeze often when thus 
exposed. 

Semeiology. — The first symptom of this affection is sneezing, 
which is soon followed by a secretion of mucus from the nos- 
trils, at first clear. The child being unable to breathe through 
the nose, as usual, lies with the mouth open when asleep. As 
the disease advances, the secretion increases in quantity and 
consistence, and the difficulty of respiration increases in pro- 
portion. The discharge, at times, completely closes the nostrils, 
and prevents sucking, from the impossibility of breathing ; he 



RESPIRATORY SYSTEM. 65 

frequently leaves the nipple, manifests fretfulness and distress, 
while the face becomes purple from obstructed respiration. 
There is sometimes danger of immediate suffocation when 
the nostrils are stopped with the secretion, on account of the 
mouth being also filled with the nipple and milk ; under these 
circumstances, also, the child is in danger of suffering from in- 
anition. This, however, is an extreme case ; and in general 
it is a disease of little danger, although exceedingly annoying 
to the child. 

The malignant variety described by Dr. Denman, is, on the 
contrary, a very serious and fatal disease. It appears to prevail 
mostly among children of bad habit of body, and is therefore 
found among those that suffer from defect of nourishment, and 
who, from breathing an atmosphere filled with impurities, are 
exposed to all the consequences resulting from these combined 
causes of deterioration in the fluids. 

Cerebral affections are the most ordinary complications of 
coryza, from the proximity of the inflammation to the brain, and 
the arrest of the circulation from the obstruction of the respi- 
ration ; drowsiness often occurs during its progress, and when 
fatal, frequently terminating in convulsions. 

Morbid Anatomy. — A great degree of tumefaction exists in 
the nasal mucous membrane, with evidences of severe inflam- 
mation, being very red and soft, and the passage filled with 
thick mucosity. The malignant or pellicular variety exhibits 
the formation of a pseudo-membranous lining, covering the whole 
nasal fossae, and in some instances it is said to have extended 
back to the fauces, oesophagus and stomach. 

Treatment. — The treatment must consist of such measures 
as will allay inflammation : this, however, is often so slight, 
that it scarcely requires those active agents which are usually 
employed. The principal source of distress, is the abundant 
secretion, the existence of which shows that nature is taking 
the proper course for the relief of the phlogosed membrane. 
Laxative drinks, made of infusion of prunes, or manna dissol- 
ved in milk, by boiling, may be given to a young infant ; and 
in cases with evident febrile excitement, some saline cathartic, 
or a little calomel, may be needed. Where sucking is mate- 
rially interfered with, from the closure of the nostrils, the child 
will have to be removed from the breast, and fed with a spoon, 
until able again to swallow the milk drawn from the nipple. 
In severe cases it may be requisite to apply a leech at the side 
of the nose, and a small blister behind each ear. 

In the malignant form, the same principles of treatment must 
be pursued. Dr. Underwood recommends castor oil particu- 



66 DISEASES OF CHILDREN. 

larly as* a laxative in this disease, observing, that debilitated 
children endure purging under this complaint better than in 
almost any other ; he recommends one or more teaspoonsful, 
so as to procure three or four motions daily. As the bowels 
show great derangement, an attention to them is necessary to 
a successful treatment of the disease ; and much greater benefit 
is to be derived from removing the acrid secretions and accu- 
mulations, than by attempts to neutralize and remove their acrid 
qualities by absorbents. Antispasmodic enemata should also 
be given on the appearance of convulsions. Opiates, also, are 
useful ; and the syrup of poppies is an excellent means of calm- 
ing the nervous irritability, and should be given every night, 
after the operation of the laxative. 

Under this course of treatment the disease will yield in the 
course of two or three weeks ; but it will be necessary to use 
some purging medicine after the discharge has stopped. The 
snuffling will often recur some time after the disease is to ap- 
pearance cured ; it will then be useful to foment the nose with 
infusion of camomile or elder flowers, and afterwards apply 
some aromatic liniment.* 

The removal of the tenacious and acrid secretion from the 
nose, appears to be a necessary means of cure. After the in- 
flammatory symptoms have subsided, it is recommended, by 
Billard, to have recourse to some extraordinary measures for 
its removal, as blowing gently a little fine calomel, or a mixture 
of sugar and alum finely powdered, into the nostrils ; before 
this, it will be sufficient to remove it gently by means of a soft 
rag. 

CROUP. 

This distressing, and often fatal disease of childhood, has, 
within fifty years, received much attention from physicians ; a 
great number of essays, remarkable for the patient and learned 
investigation they display, having appeared, to illustrate its pa- 
thology and nature. From this circumstance, also, various ap- 
pellations have been given to it, according to the views of the 
different authors who have directed their attention to the sub- 
ject. It has, accordingly, been described under the names 
of asthma infantum, angina suffocativa, suffocatio stridula, mor- 
bus strangulatorius, angina membranacea sive polyposa, tra- 
cheitis infantum, laryngo-tracheitis, diphtherite tracheale, etc. ; 
all which names express some of the most prominent symp- 
toms of the disease. The name croup, probably, is the best 



* Treatise on the Diseases of Children, etc., by Michael Underwood, M. D., p. 11. 



RESPIRATORY SYSTEM. 67 

that can be employed, from its long use, and its adoption in 
other languages ; thereby sufficiently indicating the disease, 
without being identified with the peculiar speculative opinions 
of any author, or without taking any one remarkable symptom, 
occurring in one stage only of the affection, as a type of its 
nature throughout its entire progress. 

Croup is a disease which was formerly singularly fatal ; the 
majority of those attacked with it dying. As its pathology is 
now better understood, an improvement in its treatment has 
very sensibly lessened its mortality. Vieusseux states, as the 
result of his experience, that of twenty cases occurring under 
his notice in the early part of his practice, (1775,) ten died ; 
while at a much later period, the relative mortality was very 
small, and nearly all were cured ; # and from the observations 
of Jurine, made from the closest calculations, the proportion, 
at the time he wrote, (1812,) is stated to have been one in ten. 
Other statements, made at different places, go to confirm the 
fact of the improvement in practice, in its adaptation to the 
nature of the symptoms, and the violence and rapidity of its 
progress. Michaelisf and BardJ state the mortality as in the 
proportion of two out of three. It must, however, be acknow- 
ledged, that there are a variety of circumstances controlling it, 
which render an exact computation of the proportionate mor- 
tality at different periods, a difficult task. Yet there can be 
no question as to the increased amount of cases that are cured ; 
the majority being now on the side of those who live, the re- 
verse of the result of the cases occurring half a century ago. 

It has been a question with some, whether this disease was 
known to Hippocrates, Celsus, Galen, and other ancient authors, 
from the difficulty arising from the infrequency of post-mortem 
examinations, in enabling us to ascertain whether it was a dis- 
ease described by them. That it has existed at all periods, and 
among all people, as the causes have always existed, cannot 
admit of a question. It has been found among the aborigines 
of our country, prevailing with great severity and fatality. || 
Dr. Coxe, in a learned essay,§ says, that from the first moment 
that medicine was cultivated as a science, croup has been the 
subject of observation ; and although not described as a distinct 
disease, yet records of an affection identical with this disease, 
are found in the writings of Hippocrates, Rhazes, and Avicenna, 
and in later times, in those of Platerus, Fabricius, Etmiiller, Syl- 
vius, Vigo, Ramazzini, Willis, and others. 

* Memoire sur le Croup, p. 1. 

t De Angina Polyposa, etc. ; Goetting. 1778. 

X Inquiries into the Nature, etc., of Ang. Suffoc, by Samuel Bard, M.D., 1771 

It J. D. Hunter, N. Y. Med. and Surg. Journ., vol. i. p. 311. 

5 Amer. Jour. Med. Scien., vol. iii. 



68 DISEASES OF CHILDREN. 

Martini Ghisi, of Cremona, gave a clear description of it, z» 
it prevailed very extensively in that place in the early part of 
the last century.* 

It was, however, reserved for Dr. Francis Home, in 1765, to 
give a full practical account of this disease, and to designate 
more clearly than had before been done, its distinctive charac- 
ters. The next in order, and the first American writer, is Dr, 
Rush, who addressed a letter to Dr. Millar, in London, and 
giving as his opinion, that croup is always spasmodic. In a 
subsequent work,f he, however, admits his error in regarding 
croup, in every instance, as a purely spasmodic affection, and 
that experience had satisfied him of the existence of another 
form, which, from the presence of mucus in the trachea, he 
denominated cynanche trachealis humida, and distinct from 
cynanche trachealis spasmodica. 

Dr. Samuel Bard, Professor of Medicine in King's College, 
New- York, published an essay, in 1771, on angina suffocativa, 
which is clearly the secondary form of croup, occurring after 
severe inflammatory affections of the fauces and tonsils, and 
which has, within a few years, been particularly described by 
Bretonneau and others, under the name of diphtheritis. 

A few years after, Dr. Chalmers, of South Carolina, directed 
his attention to the inflammatory affections of the larynx and 
trachea in children, and described, with great minuteness, the 
disease now under consideration.;]; 

In the year 1780, Dr. Middleton, Professor in King's College, 
in a letter to Dr. Richard Bayley,|[ makes a distinction be- 
tween genuine croup, and that form which had been known 
under the name of the sore throat distemper. § 

About the same time, Vieusseux, of Geneva, received the 
prize of the Royal Society of Paris for the best essay on this 
subject. From this period there is no disease which has at- 
tracted so much the notice of physicians, and on which there 
has been so much written ; receiving from every one a name, 
designating his peculiar view r s of its nature. In Great Britain, 
Germany, France, Russia and the United States, a great num- 
ber of monographs have been published; and, as might be 
supposed, from observations made under the varieties of cir- 
cumstances arising from difference of climate, mode of living, 
etc., much diversity of opinion would exist as to its nature and 
treatment. Most of the cases, also, especially in continental 

* Letterse Medichiee, 1748. + Medical Inquiries and Observations, 1794. 

t An account of the Weather and Diseases of South Carolina, by Lionel Chal- 
mers, M. D. ; Lond. 177G. 

II N. Y. Med. Rep., vol. xiv. p. 347. 

§ For a full account of the early American writers of Croup, see Dr. J. B. 
Beck's paper in the N. Y. Med. and Phys. Jour., vol. i. 



RESPIRATORY SYSTEM. 69 

Europe, have been described from those that have terminated 
fatally. It would, therefore, be difficult to recognise the mild 
forms or stages of the disease from descriptions taken exclu- 
sively from these cases ; and thus another cause will be found 
for the differences of opinion in reference to its nature and 
treatment. 

In addition to the ordinary interest felt by physicians in in- 
vestigating disease, an additional inducement was offered by 
the Emperor Napoleon, on the occasion of the death of a son of 
Louis Bonaparte, King of Holland, in 1807. The prize offer- 
ed for the best essay, was adjudged to two of seventy-nine that 
were presented ; one to Jurine, of Geneva, and the other to 
Albers, of Bremen. 

There are, therefore, abundant sources of information on the 
subject of croup, from men of acute observation, rich expe- 
rience, and philosophic minds. Indeed, on no subject has there 
been more talent and investigation bestowed — none, perhaps, 
where they have been followed by more practical results ; for 
the very differences of opinion have arisen, in part, from causes 
which go more clearly to illustrate the nature of the disease, 
and the advantages of its practical division into different stages. 
These remarks^ apply more particularly to croup, when caused 
by an inflammation in the mucous membrane of the trachea, or 
the inflammatory variety ; the other, or spasmodic croup, will 
receive a distinct consideration. 

Although several able writers, among whom are Bard, Ho- 
sack and Blaud, have expressed an opinion, that there exists no 
other form of the disease than that arising from inflammation, 
yet there is unquestionably a variety which arises from a spas- 
modic affection of the epiglottis ; for in some fatal cases no 
traces of inflammation whatever have been found.* It is not 
necessary for disordered action or derangement of function to 
occur, that a state of inflammation should in every case exist ; 
the excitement of the nerves, and the spasmodic contraction of 
the muscles, independent of inflammation, vident in galvanic 
experiments ; and simple mechanical pressure will at times 
produce a derangement of muscular action. 

While some have maintained the existence of inflammatory 
croup as the only form to be met with, others, Schenk, Des 
Essartz and Lobstein, contend that it never is an inflammatory 
affection. It is evident, however, that the exclusive views of 
both are erroneous ; yet those who maintain the former opinion 
are much nearer the truth, for inflammation constitutes the 
disease in the greatest number of instances. 

* See cases by Mr. Pretty, Lond. Med. and Phys. Journ., vol. iv. Also a case by 
Mr. Davis, Lond. Med, Rep., vol. xviii. 



70 DISEASES OP CHILDREN. 



INFLAMMATORY CROUP. 



Etiology. — The peculiar condition of the system in infancy 
and childhood, is the most prominent predisposing cause of this 
affection, for it is rarely found in after life ; the instances in 
which it occurs in adults, are so exceedingly few in number, as 
to be regarded as curious instances of departure from the al- 
most uniform law which appears to control its formation. This 
predisposition is doubtless in some degree connected with the 
condition of the larynx, and is probably dependent on the im- 
perfect developement of the part, but in what manner it is im- 
possible for us to explain. Dr. Cheyne regards it as arising 
from this cause, and remarks, that there is scarcely any differ- 
ence in the size of the opening of the glottis of a child, at the 
age of three years and at twelve ; after the latter period the 
aperture is suddenly enlarged, and in the male an alteration of 
voice ensues. The most accurate observers have noticed that 
it rarely occurs during the first few months after birth, but 
prevails more among children from the age of two years to 
five ; after the age of twelve, it is rarely seen. Boys are more 
subject to it than girls, according to the experience of Jurine, 
Albers and Blaud.* 

Children of robust habit and body, and who abound in blood, 
are, from this circumstance, more predisposed to croup, as they 
are to all inflammatory diseases. 

Peculiar districts of country, where there is great variety in 
the temperature, predispose children much more to this disease 
than sections where either much cold or dampness prevails, as 
has been remarked by writers who have noticed closely the 
effects of different conditions of the atmosphere. Vieusseux 
says, that the town of Geneva, although not so damp as the 
borders of the rivers or the bottom of vallies, is yet more sub- 
ject to the prevalence of croup, from the sudden changes of 
the atmosphere, from heat to cold, and from cold to heat.f 
These remarks are confirmed by observations made in this 
country by Drs. Rush, Currie, Stearns, and Archer, in their 
publications on this subject; although Dr. Home and others 
have stated, that it is particularly confined to maritime situa- 
tions. I have also remarked the effects of sudden atmospheric 
vicissitudes, in forming this disease. 

Another predisposing cause is to be found in the manner of 
clothing children with the neck and breast bare. It has been 



* Essai sur le Croup, par G. Fourquet, p. 1 1 , 
t Rapp. sur le Croup, p. 77. 



RESPIRATORY SYSTEM. 71 

observed, that croup is a very rare disease in Germany, where 
the custom prevails of clothing the children very carefully, and 
completely covering the throat with their dress. Dr. Eberle 
also remarks, that he saw but one case of croup in a number 
of years, among a large population of Germans, whose manner 
of clothing leaves no part of the breast or lower part of the 
neck exposed.* 

This affection, although found at all seasons, more frequent- 
ly prevails in autumn, winter, and the early part of spring, 
when a peculiar constitution of atmosphere appears to exist, 
predisposing to catarrhal diseases ; for it is more rife during the 
existence of epidemic catarrh and hooping cough. 

Certain other diseases, principally of an exanthematous na- 
ture, as miliary eruption, scarlet fever,f measles, small pox, J 
and thrush, appear to impart a predisposition to this disease, as 
it not unfrequently attacks children labouring under them. 
Drs. Bard, Rush, and Francis, have observed it as a sequel of 
malignant sore throat ;|| and Dr. Ferriar also relates two cases 
which occurred from the same disease.§ 

The most common exciting cause, is a sudden exposure to 
draft of cold air — a current of air blowing on the child, when 
resting, perhaps, after great fatigue ; or by any exposure, where- 
by the cutaneous transpiration is suppressed, and the serial 
passages are excited to undue action, the first stage of inflam- 
mation. To these may be added the throwing off of the bed- 
clothes, so common in young children, and the change of the 
temperature of a bed-room towards morning, in which fire is 
usually kept: a sudden check of perspiration necessarily ensu- 
ing from these causes. 

Semeiology. — Croup is usually preceded by the symptoms 
of catarrh. The child appears weary, fretful, and at times 
feverish, especially at night ; this condition alternating with cold. 
A teazing cough and coryza attend the formation of the disease. 
These symptoms may last for some days without exciting any 
suspicion. At other times, the formation of the disease gives 
scarcely any premonition. Whatever be the manner of the in- 
vasion, the incipient stage is one of the greatest importance in 
reference to the successful treatment; and, accordingly, practical 
writers have been led to recognise the disease as having three 
stages, and that it is on the prompt treatment of the disease in 

* Op. Cit., p. 347. 

t Lect. on the Prac. of Physic, by David Hosack, M. D., p. 514. 
t Cheyne, Op. Cit., p. 39. 

II Bard, Loc. Cit. Francis, Med. and Phys. Journ., vol. iii. p. 56. Med. Inq. 
and Obs., by B. Rush, M. D., vol. ii. p. 376. 
§ Med. His., vol. iii. p. 205. 



72 DISEASES OF CHILDREN. 

its incipient stage that success mainly depends. Guersent,* 
Blaud,j- and Hosack,J regard the forming stage, the catarrhal 
symptoms, as one of the most important for the treatment of the 
disease, and always preceding decided inflammatory symptoms, 
which are in their turn followed by the exudation, which is the 
characteristic of the disease. To this view every practical 
physician will bear his testimony. 

The symptoms presented by croup may therefore be divided 
into three stages, as the most convenient for clearly detailing the 
succession of symptoms, and as a guide for the proper treat- 
ment of the disease. 

The first stage is characterized by the affection being purely 
local, the irritation not extending to the whole system. In some 
instances the child will be even seen lively and playful. The 
attack usually comes on at night, and will be easily recognised 
by the loud breathing, in which the inspiration alone is heard, 
giving a sound at times resembling the clucking of a fowl, and 
at other times like the crowing of a young cock. The cough 
is frequent ; of a hoarse, dry, ringing sound. If the child is 
asleep at the time of the attack, he suddenly awakens, and ap- 
pears at times to be in great distress, often passing his hand to 
the throat. There are frequently intervals of relief, in which 
the child does not breathe with any more difficulty than when 
in health. 

In the second stage, the feeling of suffocation increases, the 
face becomes swollen and red, the surface of the body hot, 
and the pulse strong and frequent. The tongue is white, and 
all the symptoms show the existence of increased local inflam- 
mation, and general febrile action. The lungs and bronchise 
being loaded with blood, the difficulty of respiration has no in- 
terval of relief, while the arrest of the circulation through the 
lungs, produces an apoplectic condition of the brain, in pletho- 
ric children. The fauces, if examined, do not exhibit any al- 
teration ; sometimes, however, the tonsils and velum are a lit- 
tle reddened and tumefied. French writers have recourse to 
such examination, to ascertain the existence of a pellicular de- 
posit over the surface of the fauces, making a diagnosis of the 
disease ; if there should appear a grayish pellicular exudation 
in plates, the symptoms then do not arise from the existence of 
primary croup. || 

The symptoms are more intense, after renewed attacks of the 
disease, to which a child is very liable when once affected 



* Diet, de Me"d. et de Chirurg. 

■t Nouvelle Recherche sur la Laryngo-Tracheite, par P. Blaud ; Paris, 1824. 

t Hosack, Op. Cit., p. 515. II Fourquet, Op. Cit., p. 4. 



RESPIRATORY SYSTEM. 73 

with it, as it often returns for several successive nights ; and if 
not met by appropriate remedies, the violence of the disease 
increases, and as it approaches the third stage, or stage of 
effusion, the cough sometimes excites a retching, when a 
glairy mucus will be discharged by the efforts to vomit. A 
momentary relief is then experienced, but the pulse still shows 
the continuance of febrile action, while the voice remains 
hoarse. 

The application of the stethescope may be useful in ascer- 
taining the progress of the disease ; and during the interval in 
the stridulous breathing produced by vomiting, the loud mu- 
cous ronchus may be distinctly heard. The sibilant ronchus 
will also be distinguished as the disease advances, while percus- 
sion gives a dull sound in every part of the chest. 

The third stage is characterized by effusion into the trachea, 
bronchige, and on the surface of the lungs ; which in the trachea 
assumes a membranous appearance. When these symptoms 
arise, the intensity of the cough and labour of respiration in- 
crease to a distressing degree, and its whistling sound may be 
heard at a great distance. The face is high coloured and 
much swelled, the eyes are prominent and suffused, and the 
carotids beat with great force. The tongue is white, and the 
mouth dry ; the child drinking with great eagerness. The dis- 
ease continuing its progress, the sense of immediate suffocation 
is so intense, that every position is instinctively sought for re- 
lief; but the head is for the most part thrown backward, 
whereby the trachea is extended, and its capacity increased ; 
the child struggles violently to free itself from restraint, and if 
old enough, will attempt to get upon its feet. The matter vo- 
mited, either spontaneously or by means of art, consists of thick 
mucus, or portions of a white membranous substance, which 
forms the false membrane lining the trachea. There is occa- 
sional relief from the most violent symptoms, but of very short 
duration. The distress and labour of respiration increase; 
the cough becomes more hoarse ; the voice is almost a whisper. 
The child struggles more violently than ever for breath ; the 
pulse intermits, a cold sweat covers the body, the limbs are 
cold and swollen, and the circulation is evidently fast failing. 
As death approaches the cough ceases, but the suffocation in- 
creases ; and coma or convulsions close a scene of the most 
appalling distress that the physician is ever called to witness. 

Such is the usual progress of the disease when fatal. There 
are, however, other circumstances attending it, which deserve 
the attention of the physician. These are the remissions which 
are noticed during its progress, varying from some hours to 
several days, which has led some authors to regard the ex- 

10 



74 DISEASES OF CHILDREN. 

istence of an intermittent croup. This opinion, however, can- 
not be maintained, any farther than that the disease will remit, 
at very uncertain intervals. The relief is often very great, 
especially after free vomiting ; and the child falls into a quiet 
sleep, without giving the least evidence of the existence of the 
disease, suddenly, however, awaking with an attack more se- 
vere than the former. 

It not unfrequently happens that children, after a severe 
attack of croup, will recover their strength and appetite, and 
are to appearance restored to health, leaving the parents free 
from any apprehension of danger ; but a relapse will some- 
times very suddenly take place after an interval of greater or 
less duration, much more violent than the former one, and is 
often quickly fatal. The physician should therefore be guarded 
in his prognosis, and not pronounce a child to be restored, until 
the evidences of an entire relief from all the symptoms are 
placed, if possible, beyond a doubt. M. Desruelles* is of opinion, 
that it is not until after seven days have passed that the patient 
ought to be pronounced free from the danger of the return of 
paroxysms of croup. 

Without being so particular as to designate the exact time, 
the prognosis may be made with tolerable correctness, by no- 
ticing clearly the usual appearances which denote a return of 
health. If expectoration be free, discharges from the bowels 
copious, urine abundant and depositing a sediment, while the 
skin is soft and moist, and the child free from any morbid ex- 
hilaration, the remission may be pronounced to be a favourable 
one. 

It is not difficult, when these three stages of the disease are 
taken into consideration, to estimate the danger to which the 
child is exposed. In the first stage, when the disease is purely 
local, and only accompanied by cough, without laborious res- 
piration, there is little danger to be apprehended ; but when 
the respiration becomes laborious, and gives the peculiar sound 
of croup, a sound as if the air was passing through a narrow 
tube, with the cluck or crowing so remarkable in this disease, 
it is evident that the larynx is severely inflamed and tumefied, 
and if not promptly relieved, will rapidly pass to the third 
stage, or stage of effusion, which is so almost certainly fatal, as 
to have been denominated the fatal stage of croup. 

Morbid Anatomy and Pathology. — Dissections exhibit all 
the signs of active inflammation in the trachea and bronchiae : 
the mucous membrane is found red, and covered with an exu- 
dation, which is of a tubular form and solid in the trachea, and 

* Traits' sur le Croup, etc. ; Paris, 1822. 



RESPIRATORY SYSTEM. 75 

fluid and albuminous in the bronchiae ; the last mentioned se- 
cretion differing from the former only in its consistency. Be- 
sides inflammation in these parts, it also appears, at times, over 
the whole mucous membrane of the lungs, and fluid is even 
found filling the cavities of these organs. In severe and pro- 
tracted cases, serum has been seen effused in the cavity of the 
pleura. In cases of long standing, the lungs have been found 
hepatized. The morbid products of the inflammation are in 
proportion to the progress of the disease, and are very abundant 
if the child has for a long time resisted the invasion of death. 
The pseudo-membrane is generally detached from the mucous 
surface, from which it is separated by a recently exuded viscous 
matter ; it also preserves the form of the air-tubes, forming a 
species of cord.* 

In those cases which are suddenly fatal, after a disappearance 
of the violent symptoms, a closure of the trachea takes place, 
from a partial detachment of the membrane forming a sort of 
valve, which closes the passage to the lungs, as remarked by 
Dr. Cheyne. In some instances extensive inflammation has 
been found in the air-passages, on a post-mortem examination, 
without any appearance of an adventitious membrane. f In 
such instances, the peculiar symptoms of croup are doubtless 
produced by the tumefaction of the glottis and adjacent parts ; 
for the passage to the larynx is so exceedingly small in a child, 
that a slight swelling of the mucous membrane of this part will 
nearly close the passage, and produce the characteristic inspi- 
rations of croup. 

A remarkable illustration of the instantaneous effect of the 
altered state of the mucous membrane of the glottis, occurred 
in my practice a few years since, in the case of a child that 
swallowed, or attempted to swallow, some sulphuric acid that 
was standing in a cup, which a servant was using to clean 
brass, the child mistaking it for water. The respiration had 
the peculiar sound of the breathing in croup, and could be heard 
a considerable distance. 

With regard to the chemical composition of the false mem- 
brane of croup, it is composed, according to the experiments of 
Schwilgue, Desruelles, Bretonneau and others, principally of al- 
bumen, and is nearly the same as mucus, the buff of the blood, or 
the epidermis. According to the opinion of Lelut, it appears 
to arise from the mucus secreted by the inflamed part, rendered 
more rich in fibrin by the inflammatory condition, from the che- 



♦ Fourquet, Case ii., p. 20. 

t Dr. Francis's Essay in N. Y. Med. and Physical Jour., vol. iii. p. 56, and Dr. 
Jackson's Cases, N. E. Jour., vol. i. p. 385. 



76 DISEASES OF CHILDREN. , 

mical analysis of all these substances having so great a resem- 
blance. Dr. Hosack is of opinion that the membrane arises 
merely from the rapid passage of air through the trachea. 

From the symptoms and post-mortem appearances of the dis- 
ease, there can be no question as to its inflammatory cha- 
racter ; and the nature of its pathology may be suspected from 
the causes, even before the symptoms have arrived at that stage 
which gives unerring evidences of its character. The symptoms 
are, from the beginning, those of violent inflammation : the local 
pain attended with febrile excitement, and the augmentation of 
the secretions in the air-passages, clearly point out the exalted 
action of the sanguineous system. These are confirmed by 
post-mortem examination. The parts affected may be either 
the larynx alone, or the trachea, bronchise, and substance of the 
lungs themselves ; for it is evident that it is not confined exclu- 
sively to the larynx, as was maintained by Desruelles. 

When the causes of croup are considered, it is evident that 
it admits of a division into two forms, the one arising from an 
original or primary affection of the air-passages, and the other 
as a consecutive effect of disease in adjacent parts. The divi- 
sion, therefore, made by Dr. Stokes,* of primary and secondary 
croup, is a very judicious and highly practical distinction. 

Primary croup is a disease of an active inflammatory nature, 
sporadic and endemic. In this form the exudation first com- 
mences within the trachea, and spreads upwards, and is, in most 
cases, preceded by symptoms of catarrh, The secondary croup 
is the diphtherite of Bretonneau,f and, as we have already seen in 
the symptoms above described, is connected with an affection 
of the pharynx, as in scarlet fever, malignant sore throat, etc. ; 
the exudation proceeding from above downwards, while the 
ability to swallow is almost always lost. The last mentioned 
writer asserts, that inflammation of the pharynx always precedes 
croup. It is an epidemic disease, and exists without being 
preceded by catarrh. By keeping this distinction in mind, im- 
portant practical benefits will arise in the treatment, and the 
conflicting statements of different writers will in some degree 
be reconciled. This secondary affection has also been observed 
by Mr. Pretty, as following scarlet fever and malignant sore 
throat ;J and there can be no question as to the great practical 
utility of the division just stated. 

From the pathological condition of the larynx and trachea, 



* Treatise on the Diag. and Treat, of the Diseases of the Chest, by William 
Stokes, M. D., M. R. I. A. ; Dublin, 1837. 

t Des Inflam. Specialesdu Tissaix Muqueux, etc., par P. Bretonneau. 
t Lond. Med. and Phys. Journal, January. 1825. 



RESPIRATORY SYSTEM. 77 

in different instances, M. Blaud* makes three modifications of 
the disease, depending on the violence of the inflammation, and 
manifested by the nature of the secretion from the inflamed 
mucous surface. In the worst cases, laryngo-tracheitis exhibits 
itself with the most violent symptoms, succeeding each other 
with great rapidity, and almost always fatal. In this variety the 
secretion consists of a false membrane of different degrees of 
thickness, covering either the whole or a portion of the surface of 
the affected part. Another form, less severe in its progress, is 
often favourable in its termination ; in this, the secretion is 
opaque and puriform. In the mildest variety there is little 
inflammation ; it quickly disappears without the interference of 
art, while the mucous secretion is thin, limpid and frothy. 

This would appear to be a very unnecessary division of the 
subject, as there is every shade of inflammation insensibly pass- 
ing into each other, and the prognosis and treatment will de- 
pend entirely on the extent and violence of this inflammation. 
When this is light, it will yield to but little treatment, and 
will easily be recognised by the secretion not assuming the 
membraniform appearance. It often gives evidence of no 
other disease than the existence of a catarrhal affection, of 
greater or less extent ; and in proportion to the violence of in- 
flammatory action, will it need the active interference of the 
physician for its removal. 

The cough, or the peculiar sound so remarkable in expira- 
tion in croup, is observed to exhibit two kinds of sound. The 
first, acute, from the active spasmodic contraction of the mus- 
cles of the larynx, excited at first by the column of expired air ; 
the grave, which succeeds it, from the forced enlargement of 
the glottis, by the shock of the same column of air overcoming 
the contraction of the muscles. A prognosis may therefore 
be made from this fact ; for in proportion to the acuteness 
of the sound is the violence of the disease : when, on the 
contrary, the more grave the sound, the easier the muscles yield 
to the force of the expired air, and afford an evidence of the 
lightness of the affection, which is in proportion to the grave- 
ness of the sound, f 

The difficulty of respiration, also, must arise in part from the 
same cause impeding the passage of air to the lungs, and in 
part from the thickening of the mucous membrane covering the 
opening of the glottis, and the presence of the secretion, both 
in the larynx, trachea and bronchise ; and it is evident that 
death must ensue from the obstruction of the air-passages, and 
the clogging of the air-cells, by which atmospheric air is exclu- 
ded from the lungs. 

* Op. Cit. p. 18, et seq. t lb., p. 352. 



78 DISEASES OF CHILDREN. 

Treatment. — The first, or forming stage of the disease, is 
the period when the strongest impression can be made, and the 
progress of the affection at once arrested. The practical ad- 
vantage of recognising different stages in the inflammation, 
although the line of demarcation may be indistinct, is ob- 
vious, when the importance of decisive measures is considered, 
and that the successful treatment of croup altogether depends 
on the adaptation of remedies to the existing state of the inflam- 
mation, on which the train of frightful symptoms in croup de- 
pends. It is on this account that the arbitrary division becomes 
important ; and although it is not in our power to mark precise- 
ly the transition from one condition to the other with exactness, 
yet it can be easily seen by the observant physician, when the 
period of purely local excitement — the period requiring only 
the use of such remedies as will restore to the affected mem- 
brane its normal function of secretion — is passed, and when the 
necessity for speedily adopting measures to relieve the intense 
inflammation, and the febrile disturbance accompanying it, exists. 
To prevent the establishment of decided and active inflammation, 
and to remove it, when it is established, by the most prompt and 
energetic treatment, is the only effectual way of preventing its 
proceeding to the last stage, or that in which the disease is so 
often fatal. 

The attempts, therefore, to cure this most terrible of all dis- 
eases, should, if possible, be made when it is in its incipiency ; 
and when this opportunity is afforded, we never need fear the 
result. To restore a healthy action and secretion to the affect- 
ed part, an emetic will be found the most efficient, and, indeed, 
the only means for effecting it at once ; the disease having fre- 
quently been promptly arrested in its progress by this remedy. 
Tartar emetic, as a general rule, is to be preferred to any other 
article for accomplishing this object, but the employment of any 
emetic substances ought to have reference to the particular case ; 
and if the child be very young, or of a debilitated constitution, 
the use of tartar emetic may be attended with some risk, from 
the prostration of the vital powers which it produces. It had 
better be combined with ipecacuanha, and administered in a 
dose sufficiently large to produce full, free vomiting, in the pro- 
portion of a grain of the former to ten or fifteen of the latter, to 
a robust child two or three years old. The advantage of a judi- 
cious combination of other emetic substances, which also appear 
to excite an action in the mucous membrane of the air-passa- 
ges, different from the diseased action, is apparent in the use of 
squills in connection with it, or of the compound syrup of squills, 
where, from the tender age of the child, or from a feeble con- 
stitution, the use of tartar emetic is to be feared. These are 



RESPIRATORY SYSTEM. 79 

matters not to be disregarded. Having known of utter and ir- 
remediable prostration, and death quickly ensue, from the use 
of tartar emetic in young children, I have, since these unfortu- 
nate cases, been particularly guarded in its use. If the child 
has arrived at the age of two years, and possesses an ordinary 
amount of vigour, and, especially, if the disease appear to be ra- 
pidly advancing to that stage in which the whole sanguineous 
system participates in the abnormal changes above mentioned, 
a combination of tartar emetic and ipecacuanha may safely 
be used, and is powerfully efficacious in averting the develope- 
ment of febrile action, from its effects in augmenting the secre- 
tions from the liver, pancreas, kidneys, skin and intestines. 
It should be repeated every ten or fifteen minutes, until free 
vomiting is produced. A large quantity of tenacious mucus 
will be discharged; and from the altered sound of the cough, it 
will be seen that the natural secretion has been restored to the 
part ; and if the functions of the skin are also restored, the pa- 
tient may be considered for a time free from danger. 

Where there is reason to apprehend excessive prostration 
from the use of tartar emetic, either alone or combined with 
ipecacuanha, it may be administered in conjunction with oxy- 
mel of squills ;* or ipecacuanha, either in a powder or syrup, 
may with safety be given to the youngest infant; and there is 
but little hazard in an excessive dose of this medicine. It may 
be given to the youngest infant, in doses of half a grain to a 
grain, with sugar, every fifteen minutes, or half a teaspoonful 
of the syrup. After a year old it may be doubled, and given 
with greater frequency. 

However efficient the operation of these emetics may be, 
and how much soever the patient may be relieved, it still be- 
hooves the medical attendant to be prepared for a return of the 
disease ; for it will often recur at indeterminate intervals, and, 
upon the slightest reappearance of the symptoms, should be 
promptly met by the same means. The bowels ought, at the 
same time, to be moved, by a full dose of calomel, aided in its 
operation by castor oil or enemata. From five to ten grains 
may be given for this purpose, if the effects of the emetic sub- 
stances have not extended to the bowels. The main depend- 
ence, it must be recollected, is upon the free and full operation 
of emetics ; and such are the powerful effects of this class of 
remedies in arresting the progress of the disease, that prac- 
tical men, in every country, regard them as the principal re- 
source in the forming stage of croup. 

* #. Oxymel. Scillee, §j. 

Vini Antimonii, |ss. M. 
A teaspoonful every fifteen minutes, until vomiting is produced. 



80 DISEASES OF CHILDREN. 

If febrile symptoms show themselves, or if, on the first arri- 
val of the physician, there appear to exist undoubted evidences 
of inflammation, no time should be lost, but blood must be 
drawn freely, in proportion to the age and vigour of the child : 
from two to four ounces, for a child under two years, and from 
four to six ounces, for one five or six years of age. As in the 
incipient stage of the complaint the prompt administration of 
an emetic is our best resource, so on the formation of the dis- 
ease, and the establishment of inflammation, our principal reli- 
ance must be on decisive and efficient blood-letting. No time 
should be lost in attempts to relieve the child by emetics, or 
any other means, to the neglect of bleeding. The relief pro- 
cured by the loss of blood is often immediate, and if followed by 
other appropriate measures, is not unfrequently permanent. 
It more often happens that the urgent symptoms return, on the 
return of reaction, again demanding the operation of bleeding, 
which is almost with certainty followed by a mitigation of the 
disease. The extent to which bleeding is to be carried, must 
depend upon the sound judgment of the physician on the case 
under treatment ; yet, it is not to be questioned, that it has been 
carried to too great an extent ; and in no instance ought the 
child be bled to syncope, as recommended by Bayley,* Fer- 
riar,f Dick,J Chapman,|| and others. Dr. Eberle urges bleeding, 
as far as it can with safety be practised, when he recommends 
the patient to be bled in a sitting posture, with his feet im- 
mersed in warm water, until partial syncope be produced. He 
limits such copious bleeding to cases, of the most violent in- 
flammatory action, indicated by an active, firm, tense pulse, and 
a general fever. § Dr. Hosack, although an advocate for large 
bleedings in croup, does not approve of their being carried to 
such an extent as to produce fainting, having observed in seve- 
ral instances very serious and permanent evils arise from the 
excessive loss of blood. This opinion is sustained by my ex- 
perience ; and although prompt, decisive, and repeated bleeding 
is necessary, yet the constitution will often suffer from the loss of 
blood, carried to the extent insisted on by many writers, where 
the nervous system feels the effects of this remedy, as at this 
early age ; its consequences continuing for a long time after. 
There is nothing more difficult in medicine than the practical ap- 
plication of general principles ; and the judicious practitioner 
will always proportion the remedy to the circumstances of 
the case before him, and especially in the abstraction of 



* Letter to W. Hunter. 

t Med. Hist., vol. iii. p. 207. 

t Supplement to Dr. Barton's Med. and Phys. Journal, May, 1809, p. 242. 

II Phil. Journal Med. and Phys. Scien., vol. i. p. 303. 

§ Op. Cit., p. 357. 



RESPIRATORY SYSTEM. 81 

blood, keep in view, in addition to the object to be at- 
tained, its effects on the system generally, and its ultimate 
consequences ; and while the urgency of the symptoms and 
the fatal tendency of the disease are considered, the age 
and constitution of the patient, and the period of the disease, must 
also be weighed ; for, in addition to the vigour of the patient, 
there is a period in which bleeding would be decidedly hazard- 
ous, although the most prominent symptoms of the disease 
continue unsubdued ; that period when nothing more than the 
effect ufinflammation, the exudation of lymph, exists ; a period 
characterized by the loss of vital force, contra-indicating the 
use of blood-letting in any form. 

This leads me to consider the custom of local bleeding in 
croup, during the period of active inflammation, so common in 
continental Europe ; some practitioners depending altogether 
on this method of treating the disease. There are others, 
however, in France,* who recommend general blood-letting, 
as decidedly preferable to local depletion by leeches, but advise 
their use, should it be necessary to have recourse to the loss 
of blood a second time. 

Practitioners in this country rely but little on the effect of 
leeches to the throat. Dr. Dewees, indeed, is opposed to their 
use altogether, under any circumstances, never having seen 
them productive of any benefit ; but on the contrary, from the 
length of time necessary to obtain the requisite quantity of 
blood, the exposure of the throat during their application, and 
the coldness of the leeches, the symptoms of croup have in- 
creased during their application. f Another objection has been 
made to their use, arising from the difficulty of stopping the 
flow of blood from the part covering the larynx. It is, indeed, 
a serious one, and one which ought always to be considered 
when applying leeches to the throat, especially in children. 
To obviate any difficulty from this cause, it has been proposed 
to apply them immediately above the upper extremity of the 
sternum ; and, as it may doubtless at times occur that blood 
should be drawn from near the inflamed part, they may be 
with advantage applied in this situation. Dr. Dewees recom- 
mends cups, where it is necessary to use local depletion, 
applied between the shoulders, but never around the throat. 

It is, indeed, seldom necessary to have recourse to local bleed- 
ing ; for after a strong impression has been made on the circula- 



* Fourquet, Op. Cit., p. 42. 

t Treatise on the Physical and Medical Treatment of Children, by William P. 
Dewees, M. D. ; Philad. 1826, p. 441. 

11 



82 DISEASES OF CHILDREN. 

tory system, the circulation can often be sufficiently controlled 
by other remedies, and by efforts made to excite the action of 
the secretory system, thereby preserving an equilibrium, a 
means, when properly used, as powerful in the relief of inflam- 
mation as the abstraction of blood. 

Dr. Cheyne and other writers recommend drawing blood from 
the jugular vein ; but from the impossibility of ascertaining the 
quantity thus taken, arising from the constant restlessness and 
coughing of the child, and the difficulty of closing the vein for 
the same reason, it should seldom if ever be attempted ; a suffi- 
cient quantity of blood being always to be obtained from the 
arm of the youngest child, with a little practice in the efforts to 
bring the vein near the integuments, by pressing the cellular 
substance with the finger from around it after the bandage has 
been applied. I have rarely been foiled in bleeding a child, if 
sufficient time has been taken to press the part immediately over 
the spot where the vein lies with the moistened finger. A vein 
on the back of the hand, or on the foot, may also often be found, 
after having immersed the limb in warm water. 

Immediately after bleeding an emetic ought to be adminis- 
tered, if the symptoms are not decidedly improved ; and that no 
time be lost, a decided advantage will be obtained by combining 
it with a cathartic, that the whole secretory functions of the 
stomach and abdominal viscera may be excited into action.* If 
the physician has seen the case from the commencement, and 
administered such remedies as will act on the intestines, it may 
perhaps be unnecessary to repeat the cathartic immediately, if 
the progress of the disease has been rapid. But, as is most fre- 
quently the case, he for the first time sees the case during the 
period of active inflammation, when, in addition to the local 
affection, the entire circulatory system participates, it becomes 
his duty promptly to use all the means in his power for the 
arrest of this truly frightful disease. The action of an emetico- 
cathartic is a powerful adjunct to bleeding, when the symptoms 
are not relieved by this operation ; the nausea, together with the 
vomiting, and the discharge of biliary and intestinal fluids, have 
a powerful influence on inflammatory action. These active 
measures, however, are not admissible in every case ; the vio- 
lence of the inflammation, and the ability of the child to bear 
the evacuations, must be in all cases taken into consideration. 



* T$c Hydr. Subm., gr. xx. 
Antim. Tart., gr. j. 
Divid. in Pulv., No. iv. M. 
For a child three or four years old, one powder to be given every fifteen minutes, 
until vomiting ensue. 



RESPIRATORY SYSTEM. 83 

The great efficacy of calomel in croup has induced some 
practitioners to rely almost exclusively on its use in the treat- 
ment of the disease ; and it is to American physicians that the 
profession is indebted for the mercurial treatment of croup. 
Dr. Rush considered it as the main resource in managing a 
case of croup, and as certain a remedy as the Peruvian bark in 
intermittent fever. # Dr. Kuhn was in the habit of giving five or 
six grains of calomel, three or four times a day, to a child of 
two years. Dr. Redmond prescribed it in doses of three grains 
every three hours, until fifteen grains were taken, to the youngest 
and most delicate infants. Dr. Hosack also gave it in doses of 
five to ten grains every two hours, until a decidedly cathartic 
effect was produced ; and if the bleeding, emetics and cathar- 
tic failed to subdue the febrile symptoms, and to divert the irri- 
tation from the trachea and lungs, he combined it with James's 
powder, from two to five grains each, every two hours, to a child 
under four years, until a sufficient evacuation from the bowels 
was produced. Dr. Hamilton, of Edinburgh, considered calomel 
as one of the most powerful remedies in croup, and has succeed- 
ed in curing it under the most unpromising circumstances ; but 
remarks, that no relief whatever can be obtained from it, unless 
given in very large doses. He gave it to the extent of one hun- 
dred and thirty three grains in sixty hours,f to a child of seven 
years. This certainly is an enormous quantity, but not equal to 
that taken by a child of two years, to whom, under desperate cir- 
cumstances, he gave one hundred grains in twenty-four hours. J 

To an extent like this no prudent practitioner can bring him- 
self to prescribe calomel in croup, where the intestinal mucous 
surface is fully exposed to its action ; unlike the condition in some 
other diseases, where a coating of thick mucus prevents the 
immediate contact of the remedial agent, as is sometimes found 
to be the case in scarlet fever. 

Dr. Stearns, of New- York, relies principally on the use of 
calomel, combined with the cerated glass of antimony, in the 
treatment of the disease, to the entire exclusion of blood-letting ; 
regarding the disease as arising from a torpor in the absorbents 
of the trachea, and not as an inflammatory disease. He gives 
twenty grains of calomel, combined with eight grains of cera- 
ted glass of antimony, to a child one year old, when the symp- 
toms have assumed a violent character, with a proportionate in- 
crease for older children, repeated every eight hours. One dose, 
he observes, is generally sufficient, and he has never had occasion 



* Rush's Inquiries, vol. ii. p. 378. 

t Use and Abuse of Mercury, by John Hamilton, M. D. ; Edin. 1809. 

t Chapman on Croup, Phil. Jour. Med. Scien., vol. i. p. 308. 



84 DISEASES OP CHILDREN. 

to administer more than four. In connection with this he gives ■ 
a decoction of polygala senega, as an expectorant.* 

No doubt can exist as to the salutary influence of calomel 
in this disease, from its agency in exciting the secretory func- 
tions generally. It is unquestionably an active expectorant, 
especially when combined with other remedies which exercise 
an action on the bronchial mucous surface. 

The warm bath, from 92° to 98°, is an exceedingly useful 
adjunct to other measures in the treatment of this disease, par- 
ticularly in the early periods. It has a peculiarly exciting 
effect on the capillaries of the skin, producing an action in its 
exhalent function; the internal tissues are thereby relieved 
from their superabundant supply of fluids, and the local internal 
congestion and inflammation are met by a most powerful 
remedy. 

Blisters are important remedies in this disease ; and if the 
symptoms are not materially relieved by the means already 
suggested, and the state of the pulse evidently affected, one 
should immediately be placed over the throat covering the* 
larynx and trachea. Some recommend the blister to be ap- 
plied to the neck, between the shoulders ; others on the arms* 
or on the upper portion of the chest. In a disease of so rapid 
a progress as the croup, but little advantage can be derived 
from the application of a blister in a part remote from the seat 
of the disease ; and if an impression has been made on the cir- 
culation by the course already pursued, the blister should be 
applied directly over the affected part, which is first to be well 
irritated by warm turpentine ; it will very copiously deplete 
from the capillaries of the part, and aid in fulfilling the general 
indication. 

Rubefacients, however, where the disease is evidently arrested 
in its progress, will often be all the external revulsive required. 
They may consist of a sinapism, or an embrocation of equal 
parts of tincture of capsicum and tincture of Spanish flies, or 
warm spirits of turpentine. The last mentioned articles may be 
applied by friction over the throat, and a flannel moistened with 
them then put around the neck. In all affections where the 
respiratory organs are concerned^ liniments made of ammonia 
ought carefully to be avoided, from the stimulating effects of 
the volatile part of the liniment on the diseased mucous mem- 
brane. 

It very often happens, especially if the remedies above men- 
tioned have been promptly and diligently employed, that the 



* Coxe'sMed. Museum, voL v, p, 195. 



RESPIRATORY SYSTEM. 



35 



disease is relieved without manifesting the invasion of the third 
or membranous stage. Yet. from the deceitful nature of the 
intervals of respite, it is the duty of the physician to be care- 
fully guarded in his prognosis, and to employ such remedies 
as experience has instructed, as will best preserve the secretory 
functions of the tracheal mucous membrane in its normal con- 
dition, while other means are used to maintain the circulation in 
its equalized state. 

For effecting the 'first mentioned object, then, the expectorants 
already mentioned, page 46, may be used ; or perhaps there is 
nothing better than a combination of syrup of squills and anti- 
mony, or a few drops of the compound syrup of squills, every 
two or three hours. These expectorants have been found 
exceedingly valuable after the active inflammatory symptoms 
have subsided ; and when combined with antimony, their stimu- 
lating effects, so much dreaded by some physicians, are very 
materially controlled, while their expectorating qualities are sen- 
sibly increased. The physician should carefully watch the 
progress of the affection, and there will be but little danger of 
erring, by prescribing a stimulating expectorant. It even hap- 
pens that a temporary debility will exist after active inflamma- 
tion in apart, bordering on paralysis, and where a slight stimu- 
lating medicine will be needed to prevent a relapse of the 
disease ; in such a case, squills or senega may be advantageous- 
ly used, and, as above suggested, may in some cases be united 
with antimony.* Dr. Archer, of Maryland, was the first who 
introduced the polygala senega into practice as a remedy for 
croup ; and where the violence of the inflammation has been 
subdued, it is unquestionably the best that can be employed 
where the croupy cough continues, as it often does for a num- 
ber of days ; or where it has assumed a chronic form, no other 
remedy possesses so great a control as this over these pro- 
tracted symptoms. Where the addition of antimony is not 
necessary, which forms an ingredient in the compound syrup 
made of senega, it may be given in decoction, made by boiling 
an ounce of the root in a pint of water, down to three gills, 
and with the addition of two ounces of honey, in the dose of 
two or three teaspoonsful every hour or two, to a child three 
or four years of age. 

To fulfil the second indication, great care should be taken 



* # Syrup. Scillee, gj. 

Syrup. Tolu., 

Vin. Antimonii, aa gss. M. 
Eight to ten drops once in two hours, 
to a child of a year old. 



~fy Decoct. Senegse, §ij. 

Oxymel. Scillse, 3ij. 

Syrup. Ipecac, 3j. 

Antim. Tart., gr. ss. M. 
A teaspoonful every two or three 
hours, for a child two years old. 



86 DISEASES OF CHILDREN. 

to preserve a suitable warmth to the surface, by proper cloth- 
ing of flannel, frequent bathing of the feet in warm water, and 
by carefully guarding the child from any sudden exposure to a 
draft of cold air. Rubefacient applications, also, ought frequent- 
ly to be applied to the chest. 

The third stage of croup is characterized by the formation 
of a membrane in the trachea, or of a quantity of purulent 
lymph, extending even to the minute ramifications of the bron- 
chise, as far as the anatomist can trace it. In this stage the 
breathing still continues laborious, with an increasing cough, 
and which gives not the slightest relief by expectoration, while 
suffocation appears every moment about to close a scene of in- 
describable suffering. Here the treatment must be to remove 
the membranous exudation and lymph which obstruct the air- 
passages, and, if possible, to restore and maintain a healthy se- 
cretion in the inflamed part. 

As in the former stages emetics were among the most im- 
portant remedies, so in this, also, they have been found the 
most valuable resource, indeed, almost the only one on which 
we can depend, being restricted also in the class from which 
they are taken. Those of a stimulating character are here in- 
dicated, as the mucous membrane of the trachea and bronchia? 
have passed beyond the period of preternatural excitement. 
Among these the polygala senega stands foremost, and may 
be given according to the directions of Dr. Archer. He pre- 
scribes it in decoction, made by infusing half an ounce of the 
bruised root in half a pint of boiling water, which is simmered 
down to four ounces ; of this a teaspoonful is to be given every 
half hour or hour, according to the violence of the symptoms, 
with a few drops given at intervals, to keep up an action on the 
fauces, until it produce an emetic and cathartic effect ; after 
which, a small quantity is to be frequently given, to preserve a 
continued stimulating effect on the mouth and fauces. The 
powder, also, has been used with equal advantage, in doses of 
four or five grains, mixed with a little water.* By means of 
the polygala the twofold advantage will be obtained, of pro- 
curing an evacuation of the morbid secretion, and exciting the 
mucous surface to a new and altered action. Where it appears 
to affect the bowels alone, a few drops of laudanum may be 
combined with it, and will sufficiently restrain any tendency to 
pass off in this manner. 

Among the remedies which have been successfully used for 
the expulsion of the membranous formation, under circum- 
stances which afford but little reasonable hope for recovery, are 

♦ Treatise on Croup, by G. Archer; Phila. 1798, p. 33. 



RESPIRATORY SYSTEM. 87 

vitriolic emetics. The sulphate of zinc and sulphate of cop- 
per have been resorted to, when scarcely any expectation of 
relief could be indulged. The former has been used by Dr. J. 
W. Francis, of New- York, in three cases, with complete success, 
where all hopes of recovery had been previously abandoned.* 
A strong solution, consisting of two drachms of sulphate of zinc 
to an ounce of water, was made, of which a large teaspoonful was 
administered every twenty minutes to a child of two years, for 
about two hours, without effect. A solution of sulphate of 
copper, of the same strength, was prepared, and after twice 
giving it, a portion of the membrane was detached ; the white 
vitriol was then again resorted to, with the effect of dislodging 
a large quantity of similar membranous substance. Dr. Fran- 
cis, to whom the profession is indebted for the introduction of 
this remedy, remarks, that vitriolic emetics may be given with 
more safety than is generally supposed, in those cases where 
inflammatory action has been subdued. Sulphate of copper 
alone, and combined with calomel, has recently been introduced 
into practice in Germany, in epidemic or secondary croup, 
which will be considered below. 

The membrane has sometimes been expelled spontaneously 
in violent fits of coughing, and at other times been removed by 
the introduction of some chemical or mechanical irritant to the 
upper part of the oesophagus, and even within the opening of 
the glottis itself. Desault and Dupuytrenf had recourse to 
these means ; and with the assistance of a piece of fine sponge, 
moistened and fixed on the end of a small slip of whalebone, 
introduced irritating substances into the opening of the glottis. 
These are, however, hazardous experiments, and have scarcely 
ever been attended with success. M. Billard mentions the 
almost instantaneous death of a child on the application of pow- 
dered alum to the glottis. J 

Although the membrane has been removed, yet recovery has 
not in every instance followed. This should be always kept in 
mind, for recovery is generally expected where this result has 
followed the powerful means used for its expulsion. Several 
writers, Michaelis, Dewees,Cheyne,and others, record instances 
in which the membrane has been completely discharged, and 
death ensued. This, however, should not deter the physician 
from using all the means in his power for its prompt and effec- 
tual removal. 

This naturally leads to the consideration of the operation of 



* N. Y. Med. and Phys. Journal, vol. iii. p. 54. 
t Guersent, Diet, de Med. 
t Op. Cit., p. 388. 



88 DISEASES OF CHILDREN. 

tracheotomy, which has been proposed both for the purpose of 
expelling the membrane, and affording a longer time for the per- 
formance of respiration ; a brief notice of which it may be pro- 
per to give, that the whole subject of the treatment of croup 
may be duly considered. 

When all measures of a strictly medical nature have failed 
to produce a relief of the urgent symptoms in the last stage of 
croup, it was proposed, a long time since, by Home and Michae- 
lis. to have recourse to surgical means, as the only thine: left to 
be done, and where death appears to be the certain termination 
of the disease. It is indeed a desperate resource, and one which 
has not received the sanction of many eminent men, either in 
Europe or in this country, having produced the wished for result 
in but few instances. It has been tried in Spain, Denmark, 
several parts of Germany, in Geneva. Brest, Lyons and Paris.* 
In our own country it was also attempted by Dr. Physic, j in 
two instances, both of which were unsuccessful. The principal 
objections to the operation are, that it is not certain to remove 
all the causes of the obstruction to the respiration, for the te- 
nacious mucus often exists below the opening ; neither will it 
prevent the disposition of the part from forming new deposi- 
tions of membranous matter. 

Within a few years past the attention of physicians has 
been directed again to the subject ; and that it may in some 
desperate cases be successful, appears from the result of the 
dissections of M. Bretonneau, in primary and secondary croup. 
In fifty-five cases, examined by him at different ages, there were 
six or seven where the membraniform matter reached to the 
ultimate ramifications of the bronchise. In one third of the 
whole number, it extended as far as the bifurcation ; and in 
the remaining number, thirty or thirty-one, it terminated at 
different parts of the trachea. It may, therefore, be successful 
in those cases where it is confined to the upper part of the 
trachea and larynx, by maintaining respiration until the process 
of the deposition of lymph has ceased ; in the other instances 
it must be evidently of no manner of utility as a means of 
cure. To decide as to the precise seat of the affection during 
life, and thereby be guided in our opinion as to the necessity 
of the operation, must be admitted by all to be a matter of the 
greatest difficulty, if not of utter impossibility, notwithstand- 
ing the opinions of some to the contrary. M. Fourquet.J who 
strongly advocates the use of tracheotomy, records the suc- 
cessful operations of M. Bretonneau, in five cases out of seven- 

* Royer-Collard, Diet, des Sc. M6d. torn. viii. p. 417. 
t Dewees, Op. Cit , p. 447. 
t Op. Cit., p. 57, et seq. 



RESPIRATOPwY SYSTEM. 89 

teen, and of M. Trousseau, in six out of twenty-one ; five of 
which occurred in the last eleven, on whom tracheotomy was 
performed. Since the publication of M. Fourquet's essay, in 
1834, the results of one hundred and forty cases operated on, 
have been reported to the Royal Academy of Medicine at 
Paris, which probably include those just mentioned ; twenty- 
eight of which were cured, and the remaining one hundred and 
twelve died.* They were doubtless cases partaking more of 
the character of laryngitis than croup. 

When a child has once had an attack of croup, it will be 
very liable, on the slightest exposure to cold, to have a return ; 
every proper means ought, therefore, to be had recourse to by 
the parents, on the appearance of a slight cough, to prevent, at 
an early period, the full formation of the disease. When the 
child becomes hoarse, all stimulants must be withdrawn, and 
the patient confined to an apartment of agreeable warmth, and 
immersed in a tepid bath, and a drachm of the subjoined mix- 
ture given every hour ; or every two hours, if it produce 
vomiting. 7 At the same time the child should be gradually ac- 
customed to the vicissitudes of the atmosphere, while the body is 
well clothed ; and especially the neck and throat well covered. 

These remarks apply more particularly to the primary form 
of croup. It remains now to consider that variety of the dis- 
ease, which arises as an effect or a consequence of inflamma- 
tion, existing primarily in the fauces and tonsils, and spread- 
ing thence to the air-passages ; a distinction which some writers 
appear not to have noticed with sufficient care, but which 
will not be regarded as useless, as a modification of treatment 
will necessarily arise, from the difference in its nature. 

When speaking of the causes of croup, it was remarked that 
the pre-existence of other affections, known generally under the 
name of anginose diseases, were occasionally productive of 
the symptoms of croup, not unfrequently terminating in that 
disease, in its most aggravated form ; and it is unquestion- 
ably this secondary form which the late Dr. Samuel Bard de- 
scribed under the name of angina sufifocativa, occurring after 
cynanche maligna. Dr. McKenzie, professor of anatomy at 
Glasgow, has also described this form of croup as frequently 
commencing on the surface of the tonsils, and spreading thence 
along the arch of the palate, coating the superior surface of the 
velum palati, and at last descending to the internal surface of 

* Journ. des Connais. de Med., June, 1837. 
t fy. Vin. Ipecac, §ss. 

Syrup, Tolu., 

Mucilag. G. Acaciae, aa §j. 
12 



90 DISEASES OF CHILDREN. 

the larynx and trachea.* M. Bretonneau has more particularly 
described it under the name of angina pellicularis ; and from 
the identity of diphtheritis and the malignant sore throat, it is 
doubtless the same affection which was a number of years be- 
fore described by Dr. Bard. It was also remarked, that several 
eminent men have recorded the fact of its appearance as an 
effect of scarlet fever, small-pox, measles, etc. We may, there- 
fore, be prepared to find it prevailing as an epidemic disease, 
and observing the same laws as to its developement and exten- 
sion as the diseases just mentioned. It existed in this manner 
in the year 1827, in France, and was characterized by coryza 
and inflammation of the tonsils, followed by an exudation, which 
spread to the respiratory passages. Post-mortem examina- 
tions discovered a false membrane covering the membrane 
lining the nostrils, tonsils, oesophagus, glottis, larynx and trachea, 
from two or three lines in thickness.f 

In the treatment of the secondary form of croup, regard must 
be had to the nature of the primary affection. Nothing can war- 
rant the employment of active depletion in any case for the re- 
lief of the urgent symptoms of croup, as these always arise in 
the latter stage of the affection ; the depletory measures must 
be resorted to early in the disease, before the characteristic 
signs of croup have appeared. 

Topical applications, of a stimulating and escharotic nature, 
have been the measures principally used in its treatment, ap- 
plied to the fauces and tonsils. The method of treating angi- 
nose affections with topical applications is by no means modern, 
for Areteus appears to have used them, although it is somewhat 
doubtful whether he was acquainted with croup. He applied 
alum in gangrenous affections of the throat, probably under 
precisely the same circumstances as it has of late been used by 
those who have so particularly described the disease in all its 
forms, and as connected with the affection now under con- 
sideration. 

MM. Bretonneau and Trousseau relied chiefly on the use 
of astringent and stimulating topical measures ; mild caustic 
substances were applied by them in all cases of diphtheritic in- 
flammation with great success. Nitrate of silver dissolved in 
distilled water, in the proportion of one scruple to an ounce, is 
the best application in such cases. Various other stimulants, 
as diluted sulphuric or nitric acid, or chlorine, may also be used 
for the same purpose. The reader is referred to the article on 
malignant sore throat, on which this form of croup depends, for 
further details of treatment. 

* Ed. Med. and Surg. Journal, April, 1825. Med'. Chirurg. Review, June, 1827, 
t M. Borgeois, Journ. Gen. de MeU June, 1828. 



RESPIRATORY SYSTEM. 91 

In Germany, the sulphate of copper has been recently intro- 
duced into practice for the treatment of epidemic croup. Dr. 
Leoler was successful in several cases of this disease, giving it 
to a child of eighteen months, in the dose of three grains, mixed 
with a little sugar, and then a quarter of a grain every two 
hours, until vomiting followed. A teaspoonful of the following 
mixture was given to a child aged three years, which produced 
vomiting after each dose.* 

SPASMODIC CROUP. 

It does not appear that this disease was accurately described 
until the year 1761, when Dr. Simpson published an inaugural 
dissertation, in which this remarkable spasmodic affection is 
considered under the name of spasmodic asthma of infants. A 
few years after, Dr. John Millar published his work on the same 
subject,f when it received the name of Millar's asthma. Far 
from rendering the subject more clear, it appears to have added 
confusion to the description, and rendered its identity uncertain, 
both from the account of its being connected with that of another 
disease, and from its having been described in later times under 
the different names of spasm of the glottis, cerebral croup, 
laryngismus stridulus, etc. Dr. Rush published an account of 
the same affection in Philadelphia, shortly after the appearance 
of Millar's book. In the various treatises on the diseases of 
children, published within a few years, the affection has found 
a distinct notice. Wharburton, in his work on female com- 
plaints and on children, published in 1809, describes it; and in 
Clark's Commentaries, published in 1 8 1 5, a full description of spas- 
modic croup, which he refers to cerebral irritation, may be 
found. Of late, spasmodic croup has attracted much attention, 
and cases have been recorded in the different journals ; those 
particularly of Mr. Pretty and Dr. Davies have already been 
referred to. Cases have also been recorded by Mr. Hood,J 
Dr. Marsh,|| and Dr. Joy ;§ the last mentioned writer giving a 
clear and detailed account of the disease. In Germany, also, 
it has. been described by Dr. Kopp and Dr. Hirsch, and known 
by the name of thymic asthma, from its supposed dependence, 
in every instance, on an enlarged thymus gland. Dr. Ley has 

* ~fy Cupri. Sulphat., gr. v. 

Decoc. Rad. Altheeee, ^iss. 
Syrup. Althseae, §ss. 

Hufeland's Journal, Bd. 78, 1834. 

t Observations on Asthma and Hooping Cough, 1769. 
X Edinburgh Journ. Med. Scien., July, 1827. 
II Dublin Hospital Reports, vol. v. 
§ Cyclop. Pract. Med. 



92 DISEASES OF CHILDREN. 

recently published a voluminous work on this subject, charac* 
terized by extensive research and great practical experience ; 
a treatise in every respect perfect, if we except his referring 
it to the condition of the bronchial, or deep lymphatic glands, 
which, when enlarged, cause a pressure on the recurrent nerves, 
and thus paralyze the muscles they supply. It is often too quick- 
ly relieved, to have this organic affection for its cause in every 
instance. 

Etiology. — Among the predisposing causes, that which ex- 
ists in inflammatory croup, the peculiar condition of the larynx 
in children, is the most evident ; for like the other form of croup, 
it is a disease peculiar to infancy and childhood. Although in- 
stances have occurred of its existence at the ages of five and 
seven years, yet the greatest number of cases occur in children 
during the process of teething. There is, besides age, a consti- 
tutional tendency in some children, several members of a family 
being the subjects of it, as was remarked by Mr. Pretty and 
Dr. Davies, in the papers already referred to. Other practition- 
ers have noted the same fact, and that three in succession have 
been attacked when exposed to the same exciting cause. Dr. Ley 
remarks, that the affection often owes its origin to the climate 
and season. In warm climates it is but little known, and in 
dry, elevated situations it is rarely to be found. It prevails most- 
ly in damp, cold regions, and during the colder seasons of the 
year ; for this reason it appears to be unknown in those parts 
of a country which possess a warm, dry air, while in other por- 
tions that are damp and cold it is found to be very prevalent. Dr. 
Ley attributes to the change of climate in America, arising 
from the inhabited parts being cleared of the forests, and in 
consequence of this change, its great immunity from diseases 
which arise from damps and fogs, that our earlier writers speak 
of its prevalence, while at this time they doubt its existence ; 
and refers to this cause the change of opinion which Dr. Rush 
adopted, in the interval between the publication of his letter to 
Millar, in 1770, and his Inquiries, in 1794 and 1805.* Among 
other occasional predisposing causes, are found errors in diet, 
and the increased tendency to constriction of the glottis in 
scrofulous children, where there exists glandular enlargements. 
All diseases of the respiratory organs predispose the system 
to this affection. 

Dentition is the most common exciting cause of this affection, 
both on account of the high susceptibility of the nervous system 
at that period,— often manifesting itself in a slight muscular 



* An Essay on Laryngismus Stridulus, by Hugh Ley, M. D. ; Lond. 1836, p. 56, 



RESPIRATORY SYSTEM. 9J 

twitching, and which, if affecting the vocal muscles, constrict- 
ing the glottis, and thus producing the peculiar sound known 
by the name of child-crowing, — as well as from the swell- 
ing of the absorbents and glands about the neck, when the 
gums are inflamed, causing a pressure on the nerves leading to 
the part affected. An inflamed and ulcerated scalp, which is 
usually attended with enlargement of the glands of the neck, is 
also stated by him to be another cause of this affection of the 
epiglottis. 

Semeiology. — The symptoms of this disease are well related 
by Dr. Marsh. They usually occur suddenly, on awakening from 
sleep in a sort of alarm ; a violent and ineffectual effort to breathe 
takes place, which at last terminates in a long, deep sounding in- 
spiration, of a crowing sound. The paroxysm again occurs in a 
short time, while the child is awake. The face, during the 
paroxysms, shows all the evidences of obstructed respiration, 
sometimes sallow and livid. The spasm not unfrequently ex- 
tends to the other muscles, and the thumb is frequently drawn 
to the palm of the hand, while the fingers and toes are some- 
times widely spread, bearing a great resemblance to the affec- 
tion known and described as the corpo-pedal spasm. Indeed, 
being for the most part a purely spasmodic disease, when severe 
and long continued, it would be likely to affect the other muscles, 
and assume the appearance and characters of other affections 
of the same nature. If the disease be not relieved, the general 
condition of the system soon participates ; the digestion be- 
comes disordered, the bowels are consequently deranged, and 
the alvine discharges are green and slimy, while the com- 
plexion of the child becomes pale, with a general appearance of 
sinking health. The duration is very uncertain, death having 
sometimes occurred suddenly on its first invasion, and at other 
times the disease has continued for weeks, or even months. 

The spasmodic affection of the epiglottis may be known from 
inflammatory croup by the following signs : Its pathognomonic 
symptom, according to Cheyne, is a crowing inspiration, w 7 ith pur- 
ple complexion, not followed by cough. In tracheitis there is a 
ringing sound in the cough and inspiration. It does not make its 
appearance like inflammatory croup, with the ordinary symp- 
toms of catarrh, but usually in a very sudden manner, without 
the premonitions observable in that disease. It is entirely free 
from fever, unless the presence of febrile symptoms should be 
present as an accidental circumstance. In inflammation of the 
trachea, fever is an essential part of the disease, when the inflam- 
mation is established, with the ordinary signs of hot skin, high 
coloured urine, diminished in quantity. In spasmodic croup the 
pulse is small, frequent and feeble ; in the inflammatory variety 



94 DISEASES OP CHILDREN. 

it is for the most part full and strong during the inflamma- 
tory or active stage, diminishing in strength as the disease ap- 
proaches a fatal termination. 

Spasmodic croup is always to be regarded as a dangerous 
disease. If the child, however, be of a vigorous frame, and 
possess no particular disposition to diseases of the respiratory 
organs, and especially if the spasms be not very frequent, and 
no general convulsions ensue, it must not be regarded as hopeless. 

Morbid Anatomy and Pathology. — The pathology of this 
disease is still involved in obscurity. The dissections of Hirsch 
and Kopp show the trachea healthy, the thyroid and thymus 
glands tumefied, and sanguineous extravasation covering the 
trachea at the junction of these two glands. The tongue was . 
large, and thick at the root. The body generally showed the 
appearance of death from suffocation, the skin being blue, and 
congestions of blood being found in the brain and lungs. Seve- 
ral other occasional departures from the normal condition 
existed, but the thymus gland was always found considerably 
enlarged, chiefly in length and breadth, but more often in thick- 
ness ; the texture was not altered, although it was rather firmer, 
but without any trace of tuberculation, suppuration or indura- 
tion, being rather in a state of hypertrophy ; from which condi- 
tion a pressure was made on the heart, lungs and large vessels. 
Hence it received the name of thymic asthma. 

In recent dissections made in Germany by Fricke and Oppen- 
heirn,* the plexus choroides was found full of blood, effusion in 
the chest, the larynx normal ; the glottis was erect, and the 
rima glottidis open ; there were no swellings in the neck, and 
no displacement of the par vagum or recurrent ; the nerves were 
in their site, and the structure perfectly normal. The thymus 
gland did not correspond with the condition described by 
Kopp and Hirsch, but it was heavier than in the normal state. 

Dr. W. C. Roberts has recorded the post-mortem examination 
of three cases of enlargement of the thymus gland, where the 
symptoms were those of acute pneumonia. The editor of the New- 
York Journal has also given the dissection of two cases with 
similar symptoms, and the same condition of the thymus gland.f 

Dr. Ley, in the work already referred to, devotes a large 
portion of his treatise to the consideration of the pathology of 
the disease. He carefully examined the peculiar constitution in 
which it occurs, and finding the strumous deathesis to be that in 
which it most frequently occurs, endeavoured, by close investi- 
gation, to discover the connecting link between this state of the 



* Zeitschrift fur die gesammte Medicin; Hamburg, Bd. 13, Heft. 1, Jan. 1840. 
t Amer. Journ. Med. Sciences, for August, 1837, and Nov., 1838. N. Y. Journ. 
of Med. and Surg., January, 1840. 



RESPIRATORY SYSTEM. 95 

system and the peculiar symptoms of the disease. This con- 
necting link he found to be an enlargement of the thoracic and 
cervical absorbent glands pressing on the recurrent nerves, and 
thereby causing a paralysis of the muscles to which they are 
distributed.* There can be no question, that although dissec- 
tions show that mechanical pressure may, perhaps, in most cases 
be the cause of this affection, other instances have arisen from 
a simple affection of the muscles of the glottis ; for it has oc- 
curred, according to Dr. Marsh, upon the exposure of a child to 
the effluvia emanating from new paint, returning whenever the 
patient was thus exposed.f It has been referred to the brain 
by Dr. Cheyne and Dr. Clark. The existence of scrofulous 
enlargements of the glands in delicate children, sufficiently ex- 
plains this complication in those who are the most liable to the 
affection ; and the facility with which it is often removed, yielding 
not unfrequently to the removal of irritations existing in the 
gums or stomach and intestines, sufficiently proves its formation, 
independent of any mechanical pressure on the affected parts.J 
It is evidently therefore connected with a disordered state of 
the nerves supplying the muscles of the glottis, whether arising 
from pressure on the nerves themselves, or from some more 
remote cause connected with convulsive action, often inap- 
preciable on dissection. 

Treatment. — From its occurrence so frequently during 
dentition, the first obvious step in the treatment is to exa- 
mine the gums, and where they are found swollen, to make 
a free incision through them to the tooth : spasms of infants, 
wherever they occur, either in the larynx, glottis, or throughout 
the whole system, often depend upon some slight irritation, 
or painful pressure on the nerves, even in a part remote from 
the immediate seat of the affection. The condition of its 
food, also, and the state of its stomach or bowels, should be 
examined, and the proper measures taken to cause a healthy 
supply of nourishment, suitable to the age of the child, if im- 
proper food, particularly of an artificial kind, has been used. 
More particular directions for the proper food of infants, will 
be found under the head of indigestion. Daily evacuations 
from the bowels should be effected by mild aperients, com- 
posed particularly of such as will neutralize any acid in the 
stomach, if costiveness should exist. If the bowels give evi- 
dence of unhealthy secretions in the prima? vise, alteratives may 
be used, to promote a proper change in the secretions. The 
preservation of a suitable warmth by means of good clothing, 
especially around the neck, and over the chest, is of great im- 

* Op. Cit,, p 113. t Evanson and Maunsell, p. 207. 

t Dublin Med. Journ., vol. ix. p. 520. 



96 DISEASES OF CHILDREN. 

portance in the proper management of this disease. This 
should also be connected with free exposure to the open air, in 
fine weather, as one of the best means of giving vigour to the 
constitution, with suitable food as above mentioned. 

The warm bath is also an important auxiliary in the ma- 
nagement of this affection, from its tranquilizing effects on the 
nervous system. 

When it is evidently connected with cerebral congestion, or 
when it occurs in a robust child, bleeding should not be neglect- 
ed, for it often depends on the usual causes of convulsive af- 
fections, which must be discovered before a proper mode of 
treatment can be adopted. 

Rubefacient applications to the throat and upper part of the 
chest, and in severe cases, frequent blistering, will become 
necessary. When it evidently depends on a local cause, with 
an inflammatory diathesis, local bleeding by leeches will be the 
proper treatment. 

As this local affection appears to be so often the cause of 
this disease, an examination as to the enlarged condition of 
the glands about the neck and throat, is indispensable to its 
proper management. This must receive the particular atten- 
tion of the physician, if the first mentioned course of treat- 
ment fail to give relief. After the application of leeches, if 
the glands continue enlarged, with the usual evidences of a 
scrofulous habit, iodine will be the proper remedy, with such 
other measures as are used for the treatment of that affection. 
The reader is referred to that section for details of its history 
and treatment. 

In those cases unconnected with much sanguineous fulness, 
anti-spasmodics will be useful. Assafcetida was early pre- 
scribed by Millar, who administered it in excessively large doses : 
an ounce in the course of two days to a child of eighteen months. 
It is a highly useful medicine in spasmodic affections of these 
parts, from its quick and effectual operation. The proper 
dose will be, five to ten grains to a child from four to six years, 
and one or two grains for one of two years of age. Musk, also, 
has been much used in spasmodic diseases of the air-passages, 
in doses of two to six grains every six hours, to a child of three 
years ; its efficacy is so great as to cause it to be regarded by 
some as a specific. It is more useful in proportion to the ab- 
sence of febrile symptoms.* 

* Ifc Moschi, gr. vi. 

Sacchar. Albi., 3iij. 
Aquae Fceruc, §iij. 
Mist. Acacise, 3ij. M. 
A tablespoonful for a child two or three years old, every two hours. 



RESPIRATORY SYSTEM. 97 

The application, also, of tobacco, is an admirable and prompt 
remedy in an attack of this disease ; and it is owing to its quick 
influence in the spasmodic form alone, that it has obtained its 
great reputation for the treatment of croup. It is best applied 
by means of a poultice sprinkled with scotch snuff. 

During the paroxysm the child ought to be freely exposed 
to the cool air, while water is dashed in the face ; the spine 
should also be rubbed with some stimulating embrocation. 

PERTUSSIS.— HOOPING-COUGH. 

Hooping-cough was described, by the Greek and Roman 
writers, by terms significant of the violence and distress of its 
symptoms. Its nature, as might be supposed, was very imper- 
fectly understood, and no clear account of the disease was 
made until the essay of Willis.* The treatise, also, of Millar,f 
Butter,J and the works of several German authors, abound 
in practical matter. The most perfect account of the disease 
is given by Dr. Watt,|| of Glasgow. Much, however, remains to 
be known as to its nature ; and at the present day, with all the 
assistance of numerous post-mortem investigations, the precise 
pathology of the disease is but imperfectly known. 

Etiology. — The causes of hooping-cough are often difficult 
to ascertain. From its close resemblance to ordinary bron- 
chitis, in its early and forming stage, it would appear to depend 
on the ordinary causes of bronchial and pneumonic diseases, 
and exposure to cold appears often to be connected with its 
developement. The age of the child evidently has an influence 
upon the formation of the disease, for it rarely appears in the 
first two months of infancy ; yet it will occasionally attack a 
child within the month. 

Among other causes to which the production of hooping- 
cough has been assigned, that of the irritation of the bronchial 
tubes by the inhaling of the larvae of insects, was a favourite 
one of the celebrated naturalist, Linnseus.§ A similar view 
was also adopted by Rosen, with some modifications as to the 
direct influence of the exciting cause, regarding it as the effect 
of a derangement of the nervous system, by the presence of 
animalculi in the respired air.TT 

* De Morb. Convulsiv., etc., cap. xii. ; Oxf., 1667. 

t Observations on Asthma and Hooping- Cough, by John Millar, M. D. ; Lon- 
don, 1769. 

t A Treatise on Kink-Cough, etc., by William Butter, M. D.; London, 1773. 

II Treatise on the History, Nature and Treatment of Chin-Cough, etc., by 
Robert Watt, M. D. ; Glasgow, 1813. 

§ Diss. Exanth. Viva. Vide Amaen. Acad., vol. v. p. 82. 

IT Treatise on the Diseases of Children, by Nicholas Rosen, M. D. ; translated 
from the Swedish ; London, 1776. 

13 



98 DISEASES OF CHILDREN. 

It is, indeed, difficult to trace the precise agent of the disease 
with any thing like satisfaction. There can, however, be no 
question of its propagation, like scarlet-fever, by a specific 
contagion ; it has often prevailed as an epidemic, and few 
children escape when exposed to its influence, and, like other 
diseases of similar nature, it rarely occurs more than once in 
the course of life. Although, as was before remarked, it sel- 
dom attacks adults, yet this has occurred where there has been 
an exemption from it in early life, and when the individual has 
afterwards been exposed to its influence. I have recently seen 
a remarkable instance of this, in the case of an elderly female 
who had the sole charge of a child about two years old, who 
was labouring under a severe attack of the disease. She had it 
in a very severe form, with violent paroxysms of hooping, which 
lasted, with gradually lessening severity, for three or four 
months. The occurrence was during the summer, and every 
thing appeared to support the belief of its infectious nature. 

Semeiology. — The first symptoms of hooping-cough are 
those which usually accompany simple bronchitis, such as 
cough, and a slight mucous secretion. Thirst and fever, for 
the most part, accompany it ; both, however, at the commence- 
ment, very slight. In the incipient stage, which may last from 
ten days to a fortnight, it is often impossible to distinguish it 
from a simple cold, except that the cough is usually drier than 
in ordinary catarrhal affections, and attacks in paroxysms. 
These symptoms constitute the first stage. It is not long, 
however, before the cough assumes a decidedly convulsive 
and paroxysmal character. During the paroxysms of cough- 
ing a number of violent and rapidly succeeding inspirations 
are made, threatening the child with immediate suffocation. 
These fits of coughing occur at intervals of from half an hour 
to four hours or more, and when the disease is fully formed, 
the peculiar hooping sound is heard in one or two violent in- 
spirations : after a momentary rest, another fit of coughing, 
with its peculiar hoop, is heard ; these successive coughs and 
rests are at last followed by a discharge of mucus from the 
bronchise, and almost always attended with vomiting. This 
free secretion of mucus usually attends the disease when at 
its height, when the slight febrile action disappears, and the 
pulse shows no evidence of excitement during the intervals. 

During the attacks of coughing, the face and neck are 
swollen and red, with every appearance of suffocation : the eyes 
project, and the tears start, the little patient struggles violently 
for breath, and suffers great distress from this cause, instinc- 
tively seizing any object within reach that can afford support; 
and after the paroxysm, he appears much exhausted, and 



RESPIRATORY SYSTEM. 99 

sometimes becomes quite faint. In some violent fits of cough- 
ing, blood starts from the nose and lungs, and it is said even 
from the eyes and ears. 

After a paroxysm of severe coughing, in which the child ap- 
pears to be dying from suffocation, or on the point of falling into 
a general convulsion, all the distress and all the remembrance 
of suffering is at an end, for he returns to his sports with as 
much eagerness as ever. 

As the disease differs in severity, so the number of paroxysms 
differ during the day, and they are less violent in proportion to 
the freeness of the expectoration. The second stage will con- 
tinue at its height about three weeks, and then the violence of 
the symptoms gradually lessens, while the expectoration in- 
creases, and the skin becomes moist. By almost insensible 
degrees the cough loses its peculiar sound, but retains its pa- 
roxysmal character, often for a long time ; but in the simple 
form of the disease, it usually disappears at the end of the 
fourth week. It frequently happens that after an entire sub- 
sidence of the affection, it will return with the distinctive spas- 
modic hoop, on an exposure to sudden cold, or under any cir- 
cumstances favourable to the production of pneumonic disease. 

It has in some instances observed an intermittent or periodic 
nature. A case of this kind, of a peculiarly intractable cha- 
racter, which occurred daily at a certain hour, is mentioned by 
Dr. Good.* It was obstinate for several months, and returned 
at the same season for two years. 

These are the usual symptoms, in its uncomplicated form, 
except so far as a simple form of bronchitis may be considered 
a complication ; which is indeed so common, that few, if any, 
are found without it, so that the inflammation has been regard- 
ed by some as the disease itself. 

The prognosis is in general favourable. In cold and wet 
seasons it is more dangerous than in warm ; and as the disease, 
however mild at first, may be complicated with other and 
more formidable affections, such liability ought always to be 
considered in forming a prognosis. In very young children, 
and in those undergoing the irritation of teething, or during 
the existence of other circumstances which tend to derange 
the system generally, as the change of diet at the period of 
weaning, these complications are more likely to occur. As 
the connection of hooping-cough, therefore, with other affec- 
tions, from which it, for the most part, receives its fatal charac- 
ter, is of so common occurrence, the consideration of these 
complications, existing either originally, or as they arise during 

* Study of Med., vol. ii. p. 393. 



100 DISEASES OF CHILDREN. 

the progress of the disease, will be necessary to a proper un- 
derstanding of it in all its forms. 

When hooping-cough is complicated with pneumonic inflam- 
mation, it is not difficult to detect its existence, from the symp- 
toms already mentioned as distinctive marks of this affection, 
whether they give evidence of active inflammation of the bron- 
chiae, or of the parenchyma of the lungs. In the invasion of an 
extended inflammation of the lungs, which it is necessary to 
ascertain early in the disease, for its proper treatment, a change 
Will first be observed in the pulse ; which, from being but oc- 
casionally quickened during the paroxysms, becomes perma- 
nently quick and hard. So, also, the breathing is found to be 
hurried during the intervals, which, in simple hooping-cough, 
presents no departure from the healthy standard. It is unne- 
cessary to detail all the symptoms attending pulmonic inflam- 
mation, as they do not differ from those already described ; the 
rational signs are but added to the peculiar hoop of the disease, 
while the stethescope gives the same physical signs. The fa- 
tal termination is always accompanied by all the evidences of 
violent congestion of the lungs, or of a complete closure of 
the air-passages, from the accumulation of the mucous secre- 
tion following severe bronchial inflammation. 

Instead of pulmonic inflammation, there are often evidences 
of great gastric and intestinal disease ; the furred tongue, loss 
of appetite, and the altered alvine discharges, show conside- 
rable derangement of the chylopoetic viscera. These symp- 
toms, together with the existence of fever, present the dis- 
ease as complicated with infantile remittent fever. When thus 
combined, it usually exists from the commencement, and in 
many cases appears to precede it, when it is essentially con- 
nected with its developement. The approach of the fever is 
very gradual, and its commencement difficult to ascertain ; but 
the evidences of great derangement in the secretions of the 
abdominal viscera always exist before the fever has made its 
appearance. During the fever the respiration is hurried, and 
the coughing severe, but the stethescope will detect the ab- 
sence of inflammatory disease in the chest. 

When hooping-cough is connected with cerebral disturbance 
or turgescence, partial convulsions soon appear in the hands 
during the paroxysms of coughing ; these are almost invaria- 
bly followed by general convulsions. They are often caused 
simply by the interruption to the circulation in the jugular 
veins, by which the cerebral vessels are crowded with blood, 
while the face becomes livid in the midst of a fit of cough- 
ing, without the presence of a distinct hoop. These turns 
are extremely dangerous, especially in very yoUng infants, for 



RESPIRATORY SYSTEM. 101 

they almost invariably, if of frequent recurrence, terminate in 
effusion and death. The permanent dilatation of the pupil marks 
the invasion of cerebral disease. 

This complication of hydrocephalus is generally preceded 
by convulsions ; but sometimes it makes its invasion very gra- 
dually, the child giving the first intimation of it by coma, and 
paralysis of one side of the body, while the arm of the opposite 
side is moving in the sawing manner, so often observed in cases 
of cerebral effusion in children. Wherever, therefore, there 
exist . onvulsions, or paralysis on one side, we may very rea- 
sonably infer the existence of effusion in the brain. When the 
convulsion is general, before coming to the same conclusion 
we should ascertain the precise history of the case, the heredi- 
tary tendency in the family, and other circumstances connected 
with the predisposition to this disease, pointed out in the article 
on that subject. 

It may be looked for when there is great drowsiness, and at 
times screaming and starting during sleep, followed by fever 
and vomiting; while the alvine evacuations give no evidence 
of a disordered state of the secretions of the abdominal viscera. 
The breathing in the hydrocephalic complications is not quick, 
but often deep and sighing ; a remarkable difference from what 
takes place in inflammatory diseases of the chest. 

Morbid Anatomy and Pathology. — Dissection, in the sim- 
plest form of hooping-cough, has revealed but little as to its 
peculiar pathology, besides the inflammation of the bronchial 
tubes. The simple disease, uncomplicated with other affections, 
is seldom fatal ; on this account it is that autopsical investiga- 
tions have shown, in the greatest number of instances, the pre- 
sence of inflammation, and its effects in other organs distant 
from the immediate seat of the disease, as the most marked 
symptoms would indicate. It would be an unsatisfactory and 
almost an endless task, to record the results of post-mortem ex- 
aminations which have been made to ascertain the seat of this 
peculiar disease, as complications, in some form or other, have 
for the most part been its attendants. The following appears 
to be the summary ofdhe results of these examinations, and the 
theories resulting from them. 

Where opportunities have occurred, in which the disease has 
had but little or no complication, bronchial inflammation in va- 
rious stages of its progress has been found, as appears from the 
red colour of the mucous membrane, and the presence of a 
greater or less quantity of mucus at the same time in the tubes, 
together with the existence of purulent matter at their extremi- 
ties.* A dilatation of the bronchise has also been frequently 

* Billard, Op. Cit., p. 427. 



102 DISEASES OF CHILDREN. 

seen in connection with this inflammatory state, but principally 
confined to the extreme branches, as pointed out by Laennec. 
In connection with other lesions, traces of inflammation of the 
lymphatic ganglia, near the bronchia^, have existed in a num- 
ber of instances. Again, the lungs have been found in a state 
of induration, showing, in severe cases, the existence of inflam- 
mation in the parenchyma of these organs, as well as in the 
mucous membrane lining the air-passages. In other instances, 
tubercles have been discovered, in a state of suppuration, in the 
root of the lungs. 

The lesions which are found in complicated cases are as va- 
rious as the diseases which attend a protracted case of hooping- 
cough. In addition, therefore, to those above mentioned, it is not 
unusual to find chronic enteritis, worms, and other affections of 
the viscera of the abdomen. The great sympathetic and 
splanchnic nerves have exhibited a firmer consistence than is 
natural, and the cseliac plexus is considerably firmer and more 
elevated. So, also, the trunks of the phrenic nerve and the vagi 
have been found enlarged and looser in their texture. 

In other instances, the only lesion that has been found was in 
the brain, where effusion of serum existed ; from which it would 
appear to be solely dependent on the condition of the brain. When, 
however, effusion is found in the brain, it is connected with bron- 
chial affection ; so frequent is this occurrence, that it has been de- 
nominated, by some French authors, broncho-cephalite. It is 
unnecessary to record the various appearances found in this 
complication, as. they will be fully detailed when the subject of 
hydrocephalus is under consideration. 

On these appearances, when considered in connection with 
the symptoms which the disease exhibits, the different views as 
to its nature have been founded. And it is not a matter of sur- 
prise that so many different ideas of the pathology of the disease 
have existed, when the post-mortem appearances have been so 
various, and the disease often so obstinate and uncontrollable ; 
thereby apparently disproving the preceding theory, which in 
its turn, also, has been supplanted by other hypotheses. 

The theory of its purely inflammatory nature has been 
adopted by Watt, Guersent, Laennec, Billard, Dawson, and others. 
Dr. Watt especially, who wrote largely on this affection, re- 
garded it as always inflammatory, and affecting the larynx, 
bronchise and air-cells alone, when mild ; and when serious or 
fatal, it is either transmitted to other parts, or affects the original 
seat of the disease, with the usual consequences of severe in- 
flammation. The reasons for regarding it as purely and always 
inflammatory, are, that the ordinary bronchial inflammation, 
occurring in winter, not unfrequently shows a tendency to spas- 



RESPIRATORY SYSTEM. 103 

modic action ; and that the results of autopsical examinations 
in hooping-cough prove the existence of inflammation in the 
bronchial tubes, as in bronchitis. As to the precise location of 
the inflammation, Dr. Dawson is of opinion that it is exclusively 
seated in the larynx or glottis, while others think its seat to ex- 
tend throughout the whole of the air-passages. By others 
it is regarded as a spasmodic disease, arising from the condi- 
tion of the brain, or of some other portion of the nervous 
system : Cullen, Lobenstein, Le Roy, Hufeland, Jahn, Bres- 
chet and Webster, adopt this opinion ; the last mentioned 
writer seating it in the brain, and considering that the affection 
of the respiratory organs is altogether secondary, from an effort 
of nature to relieve the congested brain by an expansion of the 
chest.* Hufeland, Jahn and Breschet, were disposed to regard 
the phrenic and pneumo-gastric nerves as the original seat of 
the affection, and that the lesion constituting the disease con- 
tinued there ; while Lobenstein believed that the disordered 
action originally existed in the diaphragm, and was subsequently 
communicated to these nerves. f 

In addition to these views, M. Desruelles, in the work al- 
ready referred to, regards the disease as bronchitis complicated 
with cephalitis, the one invariably preceding the other; the 
primary affection causing a simple cough, while the subsequent 
irritation of the brain produces a spasmodic action of the respi- 
ratory muscles. 

Without adopting any of these conflicting view T s, it is enough 
for all practical purposes, to keep in mind, that at the com- 
mencement of the disease it is inflammatory: increased vas- 
cular action for the most part existing, in some instances per- 
haps in a very slight degree ; but that it is essentially the 
nature of the disease in its first stage, is evident from the fact 
of the presence of the symptoms pointing out this condition of 
parts, if the local affection be increased even but a little. 

While it is in the first stage an inflammatory disease, or per- 
haps a complication of inflammation with some inexplicable 
action of the nervous system, which modifies the simple bron- 
chitis, it is, unquestionably, in the last, one purely spasmodic, as 
is abundantly evident from the success in adopting such remedies 
in its treatment, which are known to exercise a controlling in- 
fluence over the morbid sensibility and actions of the nervous 
system. 



* Med. and Phys. Journ., Dec. 1822. 

t J. Wendt, Der Kinderkrankheiten systematise^ dargestellt j Wien., 1835. 



104 



DISEASES OF CHILDREN. 



Treatment. — From these views the treatment of ordinary 
hooping-cough may be easily deduced ; it must be antiphlogistic 
in the first stage, and when this is relieved, antispasmodics and 
sedatives will be indicated. Although our remedies should be 
at first of such a nature as to allay the inflammatory action of 
the part, yet it is evidently unnecessary to adopt any active 
measures of this sort in all cases, for in many instances of sim- 
ple hooping-cough there is but little interference needed. 
During the existence of symptoms of catarrh, the diet should be 
light, consisting of milk and vegetables, while the child is kept 
within doors, and clad warmly ; this course, together with the 
constant use of warm diluents, will tend to preserve the skin in 
a soft and active condition. At the same time the bowels should 
be kept open by mild cathartics ; a few grains of rhubarb, com- 
bined with ipecacuanha, may be used for this purpose.* If 
these do not also operate as an emetic, those of a more effective 
character may be given. Ipecacuanha, in the form of syrup, or 
the compound syrup of squills, may be used, according to the 
age of the child and the urgency of the symptoms. Proper 
formulae for emetics will be found at page 45. An antimonial 
emetic may be needed in some cases, and all measures used to 
prevent the occurrence of active inflammation of the bronchial 
mucous membrane or parenchyma of the lungs, on the pre- 
vention of which the welfare of the patient often altogether 
depends. The progress of the symptoms must be carefully 
watched, and if there exist any signs of increasing inflammation 
in the lungs, early and efficient bleeding must be resorted to, 
to prevent at once, if possible, the establishment of a serious 
and perhaps uncontrollable inflammation of the lungs. While 
the means for controlling the inflammation are in active opera- 
tion, such as will promote a free expectoration must be used ; 
and those that are applicable to bronchial and pulmonary in- 
flammations may also be had recourse to, when indicated. 

It has been the custom to be rather cautious in the use of the 
lancet, where there are evidences of much spasmodic action 
present ; but where the inflammatory condition is evidently on 
the increase, a free bleeding is absolutely necessary, and can by 
no means be dispensed with, to arrest that state of the diseased 
part which gives to hooping-cough its dangerous character, and 
which is always found after death to exist, unless the morbid 



* fy Pulv. Rhei., gr. xij. 

Pulv. Ipecac, gr. ij. 

Sacchar. Alb., q. s. M. 

Ft. Pulv. No. iv. 
One to be grven every night to an in- 
fant—two for a child of two or three years. 



# Pulv. Rhei., gr. x. 

Hydr. Subm., gr. iij. M. 

Divid. in Pulv., No. ij. 
One for an infant of six months, to be 
repeated in six hours. 



RESPIRATORY SYSTEM. 105 

action has been entirely transferred to other and distant parts. 
Leeches are highly useful, when the violence of the constitu- 
tional symptoms have been in some degree arrested, or when, 
from some peculiar debility of the patient, general blood-letting 
is counter-indicated. Like all other pulmonary affections, hoop- 
ing-cough receives but little benefit, in its simple form, from the 
use of active purgative remedies ; indeed, the unfavourable 
symptoms have at times appeared to be increased by their use, 
the operation of a cathartic scarcely ever being unattended 
with some degree of spasmodic action of the bowels, as appears 
from their griping effect. In general, it will be necessary to 
preserve a proper secretory action in the intestines, by the use 
of mild laxative medicine ; and such as have already been men- 
tioned may be used for that purpose. On some occasions, 
however, the use of these may be hazardous, when there exists a 
morbid irritability of the stomach and intestines, and other evi- 
dences of gastro-intestinal inflammation. Under these circum- 
stances, neither emetics, so useful in general in hooping-cough, 
nor laxatives, should be used, but the treatment should be con- 
ducted by the warm bath, blistering, and small doses of nitre, 
while the bowels are kept open by enemata. 

It is in the second stage, or period of spasmodic action, un- 
attended with inflammation, that the hosts of specific remedies 
have been successful ; and although their use has been de- 
nounced by some as empirical, yet experience has fully proved 
the highly practical advantages resulting from the employment 
of anti-spasmodic and sedative remedies, and that success has 
often followed a judicious use of these means. 

The extract of conium maculatum has been highly praised 
for its efficacy in allaying pulmonary irritation, and especially 
that form which constitutes the disease in question. To obvi- 
ate the objection urged against its use by some, that it arrests 
the expectoration, it has been given in combination with tartar 
emetic, by some German physicians.* When used alone, it 
may be administered in the dose of half a grain to an infant, 
and one grain to one between the ages of two and four years. 
Having had no experience in the use of this remedy, I can only 
speak from the experience of others. 

For the same purpose, opium has been extensively used. 
Henke, Millar, Kirkland, and others, extol it highly in the spas- 

* fy Ex. Conii, gr. ij. 

Antim. Potass, tart., gr. j. 
Aquce, Destill., §ij. 
Syrup. Croci., §ss. 
To be taken in the course of two days, by an infant. 

Schlesinger. 

14 



106 



DISEASES OF CHILDREN. 



modic coughs of children. Opium should always be combined 
with some nauseating remedy, whereby its controlling effect 
on the secretions may be counteracted. Dover's powder offers 
a good form for this purpose ; or the combination recommended 
by Dr. Pearson, consisting of a draught composed of a drop 
of tincture of opium, five drops of wine of ipecacuanha, and 
two grains of carbonate of soda, for a child of two years, to 
be repeated every fourth hour for several days. 

Hyoscyamus, also, is another of the narcotics that has been 
used in the treatment of hooping-cough. Its properties are ana- 
logous to those of opium ; but it does not interrupt the secre- 
tions like opium, and is on this account to be preferred. I have 
found a most decided benefit to follow its use in protracted 
cases, giving it in the extract with water, or in case of the 
presence of any slight degree of febrile action, combined with 
antimony, as recommended by Hufeland.* 

Assafoetida is another medicine that has been used with suc- 
cess for the relief of the spasmodic disease. Millar was the 
first who prescribed it, giving it in enormous doses. The Ger- 
mans, also, have used this remedy in the latter stage of hooping- 
cough, with a relief of the paroxysms, and a general improve- 
ment to the secretions generally, f Musk is another medicine 
extensively used in this disease, in the dose of two or three 
grains to infants of a year old, every hour. Belladonna, a 
powerful sedative and narcotic, and possessing, also, the quali- 
ties of promoting the excretions, has likewise been much em- 
ployed. It was used by Dr. Kahleiss, with great success, in 
one hundred cases of pertussis, in conjunction with ipeca- 
cuanha and sulphur, and the alternate use of hydrocyanic acid. 
This method has also been used by Dr. Valk, of Providence, 
R. I., with similar success.^ The subjoined formulae are those 
which he used for a child of seven months ; four times the quan- 
tity was used by Dr. K., for children of the age of two years.|| 



* fy Extr. Hyoscyami, gr. x. 
Vini Antimon., 3ij. M. 
Eight drops four times a day, to an 
infant a year old. 

fy Vini Antim., 3j. 

Extr. Hyoscyami, gr. iij. 
Syrup. Simpl., §ij. M. 
A teaspoonful every two hours, to an 
infant from six months to one year. 

t Ifc Assafoetida, 3ij. 

Mist. Acaciee, 

Syrup althaeee, aa. §j. M. 
A teaspoonful every two hours, to a 
child three or four years old. 



t Amer. Journal Med. Science, vol. 
vii. p. 417. 

II & Pulv. Rad. Bellad., gr. j. 
" Doveri, gr. ijss. 
Sulph. Precip., 3j. 
Sacchar. Alb., 3ij. M. 
Divid. in Chart. No. xx. 
One powder every three hours, and 
between each dose, twelve drops of the 
following mixture: 

fy Aquee Chamomile, fss. 
Syrupi Simpl., 3ij. 
Acid, Prussic, gt. vi. M. 



RESPIRATORY SYSTEM. 



107 



Other practitioners speak highly of its good effects, when the 
disease is purely spasmodic. 

Hydrocyanic acid has also been greatly extolled by Dr. 
Muhrbeck, of Demmin,* and Dr. Hamilton Roe ;f the latter 
especially observes, that it is so uniformly successful, that 
when he finds a child that has not been relieved by it, the first 
impression is, that the medicine could not have been good. 
Dr. Atlee, of Philadelphia, has used it in a great number of cases, 
and completed a cure in from four to fourteen days. His 
method of administering it was, to give a teaspoonful of a mix- 
ture, containing one drop of the acid in an ounce of syrup, 
twice a day to a child six months old, increasing it to three 
teaspoonsful, if no bad symptom followed its use. He adds 
•two drops to an ounce of syrup, for a child between the ages 
of one and two years, and an additional drop for each year. 
The subjoined is a prescription of Dr. Roe.J 

In protracted cases, attended with great debility, tonics have 
been resorted to, and found highly efficacious. In many instan- 
ces cinchonia has been used alone, and combined with cantha- 
rides, for the restoration of the lost strength, and to break the 
habit of a periodical return of the paroxysms. However useful 
it may have been found to be, cantbarides ought never to be 
given to very young children, from the extremely irritable state 
of their nervous system. The following is the formula recom- 
mended by the late Dr. Beatty, of Dublin. || 

Arsenic was used by Dr. Ferriar, for the same purpose, in 
doses of a drop daily of the solution of Dr. Fowler ; and Guer- 
sent advises, under the same circumstances, the oxide of zinc, a 
grain every hour. When there exists a necessity for the use 
of tonic remedies, the sulphate of quinine, probably, is the best.§ 

During the application of these remedies, stimulating embro- 
cations may be useful to establish a revulsion on the skin ; and 
the " Pommade d' Autenreith" has been much used for this pur- 
pose : *it differs but little from the tartar emetic ointment in 
common use in this country. This ointment is prepared by 
rubbing one drachm of tartar emetic with seven of lard ; a 
drachm of which should be rubbed on the chest and epigastric 



* Rust's Mag., January, 1836. 
t Treatise on the Nat. and Treat, of 
Hooping-Cough, etc. ; Lond., 1838. 
t fy Acidi Hydrocyan., (Scheele's,) 
/n\. xij. 
Liquor Antimon., Tart., 3j. 
Tinct. Opii. Camph., 3ijss. 
Musturse Camph., gvijss. M. 
A tablespoon ful every four hours, to 
a delicate boy of four years old, to be 
given in some warm drink. 



II fy Tinct. Cinchon. C, gv. 
" Canth., 

" Opii. Camph. aa. gss. M. 
3ss. — 3j. three times a day. 

§ ]£ CLuinee Sulph., gr. x. 

Acid. Sulph. Dilut., gtt. xv. 

Aq. Cinnam., §ij. M 
A teaspoon ful three or four times a day, 
to a child of two years. 



108 DISEASES OF CHILDREN, 

region, night and morning, until a crop of inflamed tumors 
appears. 

An endermic method of treating hooping-cough, although to 
accomplish a different object from that usually intended by ex- 
ternal applications, has within a few years been recommended 
by Dr, Brendt.* He employed the acetate of morphine, by 
applying a grain of the salt to the blistered surface from whence 
the skin had been removed. Four grains of powdered gum 
arabic were mixed with it, and applied by sprinkling it over 
the spot. In several instances it was attended with decided 
benefit, but not until the full effects of its narcotic power had 
been experienced. On this account it cannot be unattended 
with hazard, as we have the remedy so little under our control : 
the power of absorption differing greatly in different individuals. 

Fumigation, with the vapour of benzoin, was accidentally 
discovered, a few years since, to allay with remarkable quick- 
ness the paroxysms of hooping-cough, which had continued for 
nearly three months, during which time several remedies, in- 
cluding belladonna, had been used in vain.f The vapour of 
tar has been used by Dr. Watt with success ; and the fumes 
arising from warmed spirits of turpentine, lso said to have 
been followed by decidedly good effects. 

In all cases of obstinate hooping-cough resisting the succes- 
sion of remedies, which in all probability will be tried, a change 
of air will be often of inestimable benefit to the patient, and 
should by no means be neglected, when it is in the power of the 
patient to obtain the advantage of so powerful a tonic. It is in 
summer almost invariably followed by an improvement in the 
symptoms, and may at that season be used in all the stages 
of the disease, unless, indeed, a violent inflammation of the 
lungs should render such an exposure hazardous. 

Such are the means to be used in the treatment of hooping- 
cough, as it for the most part occurs. Inflammation of some 
portions of the pneumonic system, in a degree at least, e"ven if 
slight, so invariably attends it in the first stage, that it can 
scarcely be regarded as a complication of the disease. The 
affections of the bowels, however, and of the chylopoetic viscera,, 
generally must be regarded as a very serious complication, as 
this state of the system so often precedes hydrocephalus in 
young children. It therefore demands the closest attention of 
the physician ; and the peculiar symptoms already pointed out 
must by no means be disregarded, as upon the restoration of 



* Klinische Mittheilungen, von Dr. F. A. G. Brendt. Konigl. Geheimen Medi- 
cinal— Rathe, Greifswold, 1833-34. 
t PfafFs Mittheilunge» r lste Jahgr., 1 und 2 Heft, 



RESPIRATORY SYSTEM. 109 

the healthy action of these important viscera, the success of 
the treatment in a great measure depends. 

When, therefore, the tongue indicates the disordered action 
in the primse vise and their appendages, and a constipated 
condition of the bowels exists, it will be necessary to admi- 
nister a cathartic, which should be repeated occasionally, until 
the secretions of these parts have given evidence of a recent 
secretion, by an entire improvement in their appearance. A 
regular action of the bowels should then be kept up by the use 
of milder measures. To fulfil the first indication, calomel, in 
full doses, will be found the most effectual for the removal of 
the morbid turgescence of the abdominal viscera, and the 
speedy restoration of their functional activity. Calomel and 
rhubarb, or a few grains of calomel, followed by infusion of 
senna, will be the best to fulfil this object. After the bowels 
have been freely moved, a mixture of blue pill and rhubarb 
will suffice to preserve their action.* 

It is not unfrequently found that the secretions exhibit much 
alteration in their character, while the alvine evacuations are 
natural, as regards their habitual recurrence; it will not be 
necessary, under these circumstances, to use the more active 
purgative medicines, but simply the mild combination already 
mentioned. 

It is probably the deranged state of the secretions, and the 
predominance of acid in the imperfectly digested contents of 
the stomach, and the relief which has followed the use of alka- 
lies and absorbent preparations, combined with those that exert 
an influence on the secretory function of the bronchial mucous 
membrane, that has brought these remedies so much in repute 
as to have rendered them popular. The disease has been re- 
garded by some as in every instance necessarily connected with 
an acid state of the stomach ; such a condition is not peculiar 
to this disease alone, children suffering from any acute disorder 
have more or less derangement of the stomach and bowels. 
It is therefore always safe practice to keep this in mind, and 
whenever there is any evident derangement in the primae viae, 
to combine an antacid with the prescriptions used. It is of 
more importance than it is often conceived to be. The effects 
of acidity of the stomach are often exceedingly annoying, as 
we are all aware, producing a dull, heavy pain in the head, a 
feeling of stricture about the brain, a languor and unfitness 



* fy Pulv. Rhei., gr. x. 

Hydrarg. Oxid., gr. iij. M. 
Fit. Pulv., No. iij. 
One every night, to a child a year old. 



11*0 



DISEASES OF CHILDREN. 



for active mental exertion, but quickly relieved by neutralizing 
the acid. If such be the effects in the adult, how much more 
dangerous in the irritable condition of the infant state. It 
therefore should have our constant attention when prescribing 
for infantile diseases. It is this state of the stomach which 
probably renders the operation of an emetic, combined with 
cretaceous powder, as was used by Dr. Fothergill, so beneficial 
in the treatment of hooping-cough. 

When the secretions continue unaltered, and there is evi- 
dence of the constant presence of acid in the stomach, the hy- 
drargyrum cum creta, combined with the rhubarb, will be a good 
combination for correcting this state of the stomach, and im- 
proving the secretions ; it is peculiarly suited to the bowels of 
young children, being an extremely mild and unirritating pre- 
paration.* It occasionally happens that the bowels are in an 
extremely irritable condition, forbidding the use of laxatives 
in any form, while the secretions are in an unhealthy state. 
Here the object will be, while we attempt to improve the secre- 
tory functions of the liver and intestinal mucous membrane, to 
allay the morbid irritability of the primse viae. This is best 
done by combining the above mentioned preparation of mer- 
cury with Dover's powder,f w T hile anodyne enemata are used 
in cases of violent tenesmus and irritation in the rectum. This 
powder ought to be followed by a little castor oil, when the 
morbid irritability is removed. 

By close attention to the secretions of the bowels, and their 
appendages, we may prevent the occurrence of convulsions 
and effusion in the brain. When convulsions make their ap- 
pearance, all the usual sources of irritation in infants must be ex- 
amined, and if the gums be found swelled and inflamed, they 
must be freely divided. Convulsions will sometimes continue 
for a long time, without being in any degree relieved by the 
usual means employed for their removal. When this is the case, 
an entire change of diet will be necessary ; this subject will be 
more particularly noticed under the article on indigestion, and 
that of convulsions. 



* fy Pulv. Rhei, 3j. 

Hydr. c. Creta, gr. x. 

Pulv. Sacch. Alb., gr. x. M. 
From three to five grains every third 
hour. 



t fy Hydr. c. Creta, 3j. 

Pulv. Ipecac. Co., 3ij. 
Sacchar. Alb., 3ss. M. 
Four to six grains for an infant of six 
months, to be repeated p. r. n. 



CIRCULATORY SYSTEM. Ill 

CIRCULATORY SYSTEM. 

PECULIARITIES OF THE CIRCULATORY SYSTEM. 

At the period of birth, on the establishment of respiration, 
a remarkable change takes place in the circulation of the blood. 
The heart, from being in the foetus a single organ, like that 
of the Crustacea and pisces, intended but to send the blood 
through the vascular system, for nourishment and growth, be- 
comes double in its action, and in fact double in the arrange- 
ment of its parts. Upon the full developement of respiration, a 
new set of vessels are brought into action ; and in addition to the 
circulation of the sanguineous fluid through the nutritive capilla- 
ries, another direction is gi^en. to it, and another circulation is 
superadded — that through the lungs, for the restoration of its nu- 
tritive properties, a process hitherto dependent on the mother — 
while other vessels peculiar to the foetus are obliterated. The 
heart, then, for the first time undergoes a change in its internal 
form, by which there are two distinct organs, although united 
in one ; that on the right side transmitting the blood through 
the lungs, forming the pulmonic circulation ; the other, on the 
left, denominated the systemic circulation, for the nourishment 
of the body. Although at once entering into the full discharge 
of its functions, the heart is still peculiar, and in some respects 
differs from the adult heart. 

But before these are noticed, it is proper to refer to the changes 
which occur on the establishment of the independent circula- 
tion, and the period at which it occurs. A number of new- 
born infants were examined by M. Billard, with reference to 
the precise period at which the foetal openings were completely 
closed, and found to vary from the age of one day to that of 
eight days ; a detailed account of them may be seen by refer- 
ring to his work.* 

The result of all these investigations is, that the foetal open- 
ings are not always closed immediately after birth; but the 
period is extremely variable, occurring, however, usually on the 
eighth or ninth day after birth. The circulation ceases first in 
the umbilical arteries, next in the vein ; the ductus arteriosus is 
next obliterated, and lastly the foramen ovale. These openings 
may therefore continue, without producing any symptom of 
disease. 

The mode of the obliteration is detailed at length by the 
author above mentioned ; and the result of his observations is, 

» Op. Cit, p. 436, et seq. 



112 DISEASES OF CHILDREN. 

that the blood in the arteries is forced through by a succession 
of modifications occurring in their parietes, by which their cali- 
bre is gradually reduced in size, while in both of the fetal 
veins the arrest of the circulation occurs as the result, and not 
the cause, of the retropulsion of the blood. 

The blood of an infant, therefore, cannot, during the first 
days of life, undergo so perfect an oxygenation as afterwards, 
as it does not all pass through the lungs. M. Billard is of opi- 
nion, that it is not necessary that the blood of an infant just born 
should be charged with too much stimulating properties, and 
that this state of transition is better adapted to the imperfect 
condition of the infant frame, whose organs might be too 
powerfully excited by a sudden supply of perfectly oxygenated 
blood. 

The lungs, on the first establishment of independent life, might 
be suddenly congested ; the patulous state, therefore, of the 
ductus arteriosus affords a relief to this condition, and allows 
the blood to flow through it, as the congested state of the re- 
spiratory organs will not permit the air to arise freely in the 
cells. 

In infancy the heart, like other muscles, is much softer than 
at later periods of life, and its colour is paler; it is also much 
thinner. At the time of birth there is no difference in the thick- 
ness of the parietes ; but after the closure of the fetal openings, 
those of the left ventricle, from the increased demand made on 
them as the entire source of transmission of blood through the 
systemic circulation, rapidly increase in thickness, until they 
become four times as thick as those of the right. 

At this time, although the parietes of the heart are the same 
in thickness, the cavities differ in their capacity, the left ven- 
tricle being much the largest. Gradually, however, after birth, 
the capacities of these cavities are reversed, that of the right 
side becoming the largest, from the causes already stated, which 
produce an alteration in their parietes. The colour of the right 
cavities is usually of a deep violet. In this respect they also 
differ from the left, which are of the usual red. The larger vessels 
of this side also present the same colour, which does not appear 
to depend on venous turgescence. 

As the organs of circulation are in an active state even du- 
ring the fetal life, the nerves of the ganglionic system, which 
supply the heart and involuntary muscles, are much more de- 
veloped than those of the cerebro-spinal system. 

The heart of an infant is of large size, but possessing less 
powers than the heart of an adult ; it is, therefore, more fitted 
for the transmission of a large quantity of blood, but not to so 



CIRCULATORY SYSTEM. 113 

great a distance. Its great irritability, or, as it has been termed, 
organic force, renders its contraction much more active than in 
after life ; a remarkable provision, by which the demand of the 
system for nutrition, during the period of growth, is quickly 
supplied, for a large quantity of materials is constantly needed, 
at a time of life which is characterized as one of transition from 
an imperfect state to a state in which all the organs are adapted 
to the full performance of their functions. 

Jacquemier, in his treatise on auscultation, has endeavoured 
to establish the medium pulsation of the heart of an infant ; and 
after a great number of experiments, has found the minimum 
pulsation in a new-born child to be 97, the maximum, 156, and 
the medium, 126.50.* 

M. Lediberder, in a memoir on the changes occurring in the 
circulation of an infant at the moment of birth, states, that the 
result of auscultating the heart, even before the umbilical cord 
was cut, gave 83 double pulsations in the first minute ; but 
they quickly increased in number, for after the third minute 
the medium pulsation in sixteen cases, was 160.f 

The pulsation of the radial artery, which is not always iso- 
chronous with that of the heart, has been variously stated by 
different authors : Floyer fixed it at 134, Haller, 140, Soem- 
mering, 170. Billard states, that the pulse in new-born chil- 
dren often does not exceed that of an adult, but that it increases 
in frequency in proportion as the child advances in age ; and 
in the generality of cases, the pulse of children is more frequent, 
he observes, than in adults. 

In a great number of experiments conducted by M. Valleix, 
the average pulsation, at the age of 2 to 21 days, amounted to 
87; at 64.7 months, to 108.31; at 23.6 months, 121.68; at 
11 months, 129.9; at 14 months, 125.66; and at 20 months, 
11 7.75. J The pulse, at the age of 7 months, is much more 
frequent than at a few days after birth; it afterwards di- 
minishes until the age of 6 years ; after this period, there has 
been nothing ascertained as to the effect of age on the pulse. 

The healthy pulse of infants is very soft, and easily com- 
pressed ; the artery, instead of striking the finger, appears to 
glide under it, requiring some care in pressing on the vessel. 
The crying of the child has a very marked effect on the pulse, 
even before it has commenced ; for when a child is about to cry, 
there is often so great an increase in the pulsations, that it is 
difficult to count them. With respect to the ordinary charac- 



* Del' Auscultation applique au Systeme Vasculairedu Foetus, etc.; Paris, 1827. 
t Valleix, Op. Cit., p. 26. 
t Op. C it., p. 25. 

15 



114 DISEASES OP CHILDREN. 

ters of the pulse, as indicating disease, they do not differ from 
that of an adult ; but this subject will be considered in the next 
section. 

Among the many differences existing between the child and 
the adult, arising from the demand for the materials for growth, 
there is none more remarkable than the proportion which the 
blood-vessels bear to the other organs. The arteries abound 
in every part of the infant frame ; and during this period of ac- 
tive interstitial deposit, the sanguineous appearances are very 
remarkable in every part of the structure, even of the most 
solid, when subjected to anatomical examination. These gra- 
dually disappear after the period of youth, and are scarcely to be 
found on separating the periosteum from the bones in old per- 
sons. This contraction and disappearance of the arteries take 
place in the extreme branches ; and, as was observed by Bichat, 
the younger the subject the more easily could injections used 
for making anatomical preparations be made to pass to the mi- 
nute portions of the arteries ; while in the old, such is the resist- 
ance which the contraction of the smaller vessels oppose, that 
it is with difficulty that even the largest trunks can be filled. 
At an early age, also, the coats of the arteries show very plain- 
ly the existence of the vessels which belong to them, but which 
gradually disappear in after life. 

The changes thus occurring in the arteries, depend on their 
containing much more cellular substance than the veins ; and 
the increasing condensation of this substance produces a thick- 
ening of the vessel. Changes to such an extent, however, do 
not occur till late in life ; and this is the reason why the young 
are more subject to arterial hemorrhage than the old ; for, in 
the former, the quantity of blood in the arterial system is al- 
ways most abundant, and the power of contractility of the 
arteries much greater ; all this tends to distend the extreme 
parts of the arteries, and also to add to the bulk of the body. 
In the old, the veins have gradually dilated, while the arteries 
have contracted their calibre ; the arteries, therefore, yield more 
readily to the force of the circulation in early life, and the ple- 
thora of young people is that of the arteries, while in age it is 
in the veins. 

As the capillaries are the principal agents in the nutrition of 
the body, and necessarily form the most intimate part of the 
texture, they must therefore abound at the early period of life, 
when the increase of parts is the most characteristic pheno- 
menon. On this account, also, it is that diseases in early life 
are so sudden and so violent, and require more prompt and en- 
ergetic treatment than those of adults : all the morbid phe- 
nomena having their seat in the capillary system, which is at this 



CIRCULATORY SYSTEM. 115 

period of life in so active and vigorous action in building up 
the body. 

The quantity of blood in the body of an adult, is estimated 
by Haller at about one fifth of the weight of the body ; but as 
all the fluids abound in infancy and youth, the proportion is 
much greater in early life, when the continued addition of new 
materials is more needed than at an after period of life. The 
consequences of this activity of the circulation and redundancy 
of fluids, may be traced in all the organs. The blood is not only 
sent in abundance to every organ, but is better prepared, by the 
air acting on a much larger portion of it in a given time, for 
the purposes of nutrition and secretion. The round and plump 
form of the infant, and the softness of all its parts, show 
this redundancy, while the bright red colour of the skin gives 
evidence of the constant circulation of aerated blood through 
its tissues. 

There is also a difference in the composition of the blood in 
infancy and early life. At this period, the proportion of azote 
is less than in advanced life ; the watery exhalations also are 
greater, and the fibrine less. In the foetus there is no fibrine at 
all, but the blood contains in its place a gelatinous substance, 
which does not become reddened by contact with the air ; 
neilher are there any phosphoric salts found in this fluid.* 
Phosphate of lime and fibrine increase with the growth of 
body, and the former, in adult age, sometimes becomes exces- 
sive. In proportion to the increase of these elements the quan- 
tity of gelatine diminishes, and also changes in quality, as is well 
known to glue manufacturers, for the glue obtained from the 
young differs materially from that yielded by adult animals. 

The condition of the secreted fluids naturally falls under an- 
other division of the subject, and will be considered when the 
lymphatic apparatus comes under our notice. 

SIGNS OF DISEASE FROM THE CIRCULATORY SYSTEM. 

Affections of the heart, during the first periods of life, gene- 
rally arise from congenital lesions, in which they differ from 
the abnormal state in the adult or advanced age, where 
they arise from ossifications, or from diseases of the bronchise 
or lungs. Contractions in infancy arise from fibrous or cartila- 
ginous degeneration, while they are of an osseous nature in old 
persons. 

Palpitations often arise in young girls, which do not occur 
from any organic lesion ; they usually disappear on the esta- 

* Fourcroy, Anal, de Ghimie, t. vii. p. 162. 



116 DISEASES OF CHILDREN. 

blishment of the catamenial discharge. It is unnecessary to 
detail at length the various signs of diseases which may be 
drawn from the pulse and appearances of the blood ; these do 
not differ from those in similar diseases in adults, the difference 
in frequency being taken into consideration. The following 
signs, however, are peculiar to many diseases of children. 

A frequent pulse may occur in inflammations, especially of 
the mucous, synovial and serous membranes ; but a frequent 
pulse seldom occurs in inflammation of the brain : it is, on the 
contrary, strong, hard and full. 

The pulse is also frequent in extreme debility, when it will 
at the same time be found small and weak ; it then yields an 
unfavourable prognosis after the continuance of acute disease, 
as it indicates the first degree of effusion in hydrocephalus, etc. 

The rare pulse is an evidence of very severe cerebral disease, 
especially where there exists great pressure on the organ, as 
in hydrocephalus, or tumors of the brain. This kind of pulse 
also exists in cardiac diseases, when arising from any obstruction 
in the circulation; hence it is found in cyanosis of children. 

An intermittent pulse will occur when there is a congenital 
malformation of the valves of the heart, and in all diseases of 
the lungs and pleura, where a part of the lungs have become 
impervious, or the entrance of the air has been prevented. In 
inflammations and effusions in the brain, and in spasmodic 
affections, the pulse will become intermittent ; and where this 
peculiarity arises in gastric disorders and worms, it is explained 
by reference to the derangement of the nervous system. 

An irregular pulse is a higher degree of the intermitting. It 
points but the existence of higher grades of the diseases above 
mentioned. 

An unequal pulse is an unfavourable sign at all ages. It is 
not very common in young children, but it often occurs in 
diseases of the brain ; and it is also an evidence of obstruction 
of the circulation, from effusion in the pericardium, or of conge- 
nital diseases of the heart. 

A strong pulse is an evidence of inflammation and conges- 
tions in different organs. A weak pulse is a sign of debility ; it 
also occurs in gangrene, softening, or purulent infiltration. 

A full pulse is a sign of plethora ; and it is often the precur- 
sor of hemorrhages, evacuations and exanthematous eruptions. 

A hard pulse indicates inflammation or spasm. The hard 
pulse of spasmodic disease is distinguished by its smallness and 
irregularity, whereas in inflammation it is strong and regular. 

The attempts to discover organic affections by the pulse 
have not been successful. It is of more value to discover the 
character of the disease in general, and for making a prognosis, 
than for discovering the seat of the disease. 



CIRCULATORY SYSTEM. 117 

DISEASES OF THE CIRCULATORY SYSTEM. 
CYANOSIS, 

Cyanosis is characterized, as its name imports, by a blue ap- 
pearance of the skin ; whence the names of blue disease, puer 
ceruleus, cyanopathia, as it has been at different times called, 
It is the blue jaundice of the ancients. 

Infants at birth are often cyanosed, from an impervious state 
of the lungs, or from an inefficient action of the respiratory 
muscles ; it also arises from pressure on the brain, after severe 
labour. This condition has been already considered in the ar- 
ticle on asphyxia of new-born children. The disease now to 
be considered, is that which persists after the establishment of 
respiration for an uncertain length of time, even to full adult 
age. For the most part, children thus affected, if they survive 
the period of infancy, die soon after they have attained the 
age at which they commence the use of the most powerful 
muscles of the body in walking. 

Etiology. — The causes of this affection necessarily include 
the morbid anatomy and pathology, for it arises from a con- 
genital malformation, or persistence of the natural foetal open- 
ings of the heart, or of some dilated or thickened state of the 
right cavities. It is not the blue appearance of the skin, which 
arises from a peculiar condition of the capillaries, and a stasis 
of venous blood in the surface, such as is found towards the 
close of pulmonary diseases, fevers, and the Asiatic cholera. 

There have been several dissections, by Corvisart and others, 
of persons who have been affected with this blue colour of the 
skin, in whom no continuance of the foetal openings, and a per- 
sistence of the partial foetal circulation, was found to exist — the 
usual cause of these symptoms. On the other hand, Fourquet, 
Breschet,* and Crampton,")- have recorded ca-ses, in which a 
large communication has existed between the two ventricles,, 
without the presence of a cerulean hue of the skin, or the ex- 
istence of the distressing symptoms usually accompanying an 
imperfect condition of the heart. In one instance the foramen 
ovale has been found open even to old age, without much inter- 
ference with the functions of the body. J The latter are cu- 
rious exceptions to the general rule, for it can scarcely be con- 
ceived that a large quantity of venous blood can be transmitted 
into the arteries, without interfering in some degree with the 
functions of the body. 

* Diet, des Scien. Med. 

t Med. Trans, of the Coll. of Phys. in Dublin, vol. i., New Series. 
t Geschichte einer Chir., Privatgesellschaft in Kopenhagen. Bertholin. Anal., 
Lib. li. 



118 DISEASES OF CHILDREN. 

Whenever a cyanosed state of the system exists, unconnect- 
ed with protracted disease, it results in every instance from a 
malformation of the heart, by which a portion of the venous 
blood is mixed with the arterial, or from some condition of 
the lungs, whereby blood sent to them is not properly 
changed by the vital and chemical actions, which in a normal 
condition of the lungs occur in them. In those instances where 
cyanosis does not take place, and the foetal circulation in part 
remains, it is doubtless because the blood passes through the 
lungs in sufficient quantity to become oxygenated to such a de- 
gree, as to render the venous blood, with which it is mixed, 
sufficiently altered for the purposes of nutrition and growth. 

Anatomical examination, however, has established the fact, 
that the right cavities of the heart are always found altered 
in size, whether there exist an opening between the two sides 
of the organ or not ; and the livid colour of the lips is an in- 
variable sign of lesions in the right side of the heart. 

The disease, therefore, does not always depend on an imper- 
fect closure of the foramen ovale, but in the greatest number of 
instances, especially when accompanied by the symptoms which 
will be described in the next section, this imperfection doubtless 
exists. As has already been stated, the persistence of the inter- 
auricular opening and arterial duct does not, in the first days of 
life, produce any very remarkable symptom, nor does it after- 
wards, if the blood is in reality sufficiently oxydized. In gene- 
ral, however, especially if there exist much plethora, and the 
respiration be imperfectly established at first, from the constant 
interference of a partial foetal circulation, the disease known by 
the name of cyanosis, or puer ceruleus, results from this con- 
dition of the heart ; for if any alteration from the normal action 
occurs, by which the heart performs its part in the circulation 
of the independent being but imperfectly, and fails in transmit- 
ting the blood to the lungs, the unchanged venous blood must 
be sent into the general circulation. That this does occur, ap- 
pears from the singular case described by Dr. Sandfort. This 
was a boy, who had been affected with asthma from the second 
year until his death, which took place in his thirteenth. He was 
of a leaden colour, and known as the blue boy. On making an 
autopsical examination, the aorta was found to arise from both 
ventricles, while the pulmonary artery was of so small dimen- 
sions as scarcely to admit a probe.* There are several other 
instances recorded, where the disease was connected directly 
with openings between the ventricles; the patients living to the 
sixteenth and twentieth year with great distress. f Dr. Baillie 

* Observationes Anatomico-Pathologicse; Lugd. Bat. 1777, quoted by Dr. Good, 
t Morgan, de Sed. et Caus. Morb. £p. xvi. 



CIRCULATORY SYSTEM. 119 

gives the case of a child who lived two months, where the aorta 
arose from the right ventricle, and the pulmonic artery from the 
left;* in this case, and other similar ones, the colour was uni- 
formly blue.f A remarkable case of an accidental occurrence 
of the formation of a passage between the two ventricles, from 
some injury, as was supposed, is recorded by Corvisart. It 
occurred in a boy who died at the age of twelve years, and who 
had not manifested any symptoms of irregular respiration until 
within five months of the time of his death, when the whole train 
of distressing symptoms for the first time made their appearance. 

With these remarkable facts, and the similarity of the condition 
of the heart of a young infant, the distressing symptoms which 
characterize the disease in question, may, in most cases, be attri- 
buted to the continuance, in some degree, of the foetal circulation; 
and in all, whether it has existed with a malformed heart or 
not, it indicates an imperfect oxygenation of the blood ; for a 
partial cyanosis may exist in severe congestion of the lungs, 
when the lips and alse nasi will become of a livid colour. 

Semeiology. — When a young infant is affected with this dis- 
ease, the respiration is at intervals very laborious and distress- 
ing, sometimes accompanied with loud screams. Immediately 
after each fit, the face, which before was of a bluish colour, re- 
turns to its natural hue, and the pulse becomes regular. In a 
few minutes the respiration is entirely suspended ; the eyes are 
vacant, the hue of the face changes ; it is more particularly of a 
deep blue on the upper lip, while the pulse is extremely irregu- 
lar. In the course of ten minutes the blueness extends over 
the whole face ; afterwards the extremities become blue and 
cold, and the pulse scarcely perceptible. While in this condi- 
tion the child suddenly screams, is convulsed, and with two or 
three sudden inspirations the circulation is again restored, the 
leaden colour disappears, and the skin recovers its natural hue. 

Such are the symptoms attending violent paroxysms of the 
disease in young infants. In others it is not so severe, although 
in all there is great distress in breathing, on the occurrence of 
any circumstances which will excite an increased action of the 
heart. The child will continue for three or four years with 
the skin completely blue, and without the occurrence of any 
untoward symptom of a sudden or alarming nature. But when 
he has arrived at the age at which he commences the use of 
his limbs in walking, the increase of circulation from this cause 
embarrasses the heart in its action, and repeated fainting fits 
are the result. The child thus affected scarcely survives this 

* Morbid Anatomy, Plate vi. p. 21. 

t Transact. Medico-Chirurg. Soc. Edinb., vol. i. Art. vi. by Dr. Holmes. 



120 DISEASES OF CHILDREN. 

period of life; but, as has already been stated, cases hafe oc- 
curred where a wretched existence is prolonged, even to puberty 
and adult age. 

Treatment. — In the violent paroxysms above stated, occur- 
ring in young infants, and threatening almost immediate death, 
the object should be to sustain the vital energy of the sinking 
frame, until the heart has in some degree recovered its tone, 
from the congestion both in its cavities and in the pulmonary 
system. For this purpose there is nothing so effectual as a 
stimulating bath, aided, in severe cases, by a blister to the chest. 
Dr. Hosack, in the appendix to the American edition of Thomas's 
Practice, gives the successful result of two cases treated by 
these means. The children were placed in a bath raised to a 
temperature a little above the natural temperature of the body, 
composed of an infusion of Peruvian bark and brandy, with 
the addition, from time to time, of a little aqua ammonise. The 
violent paroxysms were quickly relieved, and the children re- 
covered. 

In the other form,' but little can be done besides keeping the 
child as much at rest as is possible, confining him to a light diet, 
and preserving the bowels in a soluble condition. There have 
been instances where the blue skin has gradually disappeared, 
arising from the natural removal of the organic causes of the 
disease. 

INFANTILE REMITTENT FEVER. 

Febrile disorders, of a remitting nature, are of very common 
occurrence in children, and rank next in frequency to croup, 
pneumonia and diarrhoea. The first clear and distinct account 
we have received of the remittent fever of infants, was written 
by Dr. Butter, in 1782;* although there exist, allusions to a 
similar affection in children in the works of Sydenham, Sauva- 
ges and Hoffman, under the names of hectica infantilis, and 
febris lenta infantum. 

Etiology. — The predisposition to a remitting form of fever 
in children arises from the peculiarly irritable condition of the 
nervous system, by which the circulation is easily excited to 
undue action, and as quickly exhausted of its accumulated ex- 
citement. This condition is more remarkable where an irri- 
tative action is present in some portion of the intestinal canal. 
The irritation of teething, also, often gives rise to similar symp- 
toms. The variations of atmospheric temperature, cold or damp, 
may occasionally excite the disease. It has at times prevailed 

* Treatise on Infantile Remittent Fever, by William Butter, M. D. ; London, 

1782. 



CIRCULATORY SYSTEM. 121 

as an epidemic, and by some has even been supposed to have 
been contagious. The sudden suppression of an eruptive dis- 
ease has not unfrequently been a cause of remitting fever. The 
excitement, however, of the intestinal mucous membrane is the 
great source of remittent fever of children ; but the immediate 
exciting cause will appear more at length when the symptoms 
and pathology are considered : it will on this account be ne- 
cessarily left to be considered under the section on the pathology 
of the disease. 

Semeiology. — The remittent fever of infants is very slow in 
its progress, and its first symptom is irregularity of the bowels ; 
sometimes costive, and at other times relaxed. There are 
several accessions of fever during the day, accompanied with 
great drowsiness. Dr. Butter makes three different forms of 
the disease ; these he denominates, from the most prominent 
symptoms, the acute, the slow, and the low infantile remittent 
fever. The distinction can scarcely be applied to practice, 
although the varieties unquestionably exist. Without going into 
the detail of the symptoms of each, it is sufficient to remark, 
that the difference is found principally in the mode of invasion. 
Thus, the acute is violent in its attack, and generally preserves 
more of the inflammatory character during the progress ; the 
slow, although with much the same detail of symptoms, is yet 
more imperceptible in its invasion ; while the low variety is 
distinguished by the determination to the brain, and the occa- 
sional presence of delirium, succeeded by a low, quiet state : 
the child being indifferent, and at times insensible, to surround- 
ing objects. 

All the occasional forms of this disease may be comprised 
in the following symptoms, variously altered, according to the 
violence of the fever, or the attending complications. 

The strength is observed to decline gradually, the abdomen 
is tumefied, and the breath offensive. One of the most re- 
markable symptoms is the itching of the nose, which induces 
the child to be constantly picking or scratching it. The sleep 
is much disturbed, and he is observed to grit the teeth, and oc- 
casionally to start in his sleep. These symptoms are followed 
by a chill, which is succeeded by fever ; first making its attack 
during the night. Before the fever is fairly established, there 
are several exacerbations in the twenty-four hours ; and during 
the remissions the child appears almost well. These accessions 
are at first slight, soon, however, they become more severe, and 
the intervals short. The exacerbations are then generally 
about three in number, during the day ; the last, occurring in 
the evening, sometimes lasts through the whole night, until 

16 



122 DISEASES OF CHILDREN. 

morning, and are very distinct when the disease is fully 
formed. 

From the commencement there is a total loss of appetite, 
with foul tongue, and constant thirst. Every symptom shows 
the digestion to be entirely suspended ; and alter the disease 
has continued for a few days, the nausea, which always attends 
the taking of food, increases, until the child vomits every thing 
it. swallows. The intestines, also, lose their power, for the food 
passes off without any other change than that produced by 
putrefaction. 

During the fever, when the disease is fairly established, the 
pulse is from one hundred and forty to one hundred and sixty. 
The skin is dry, the surface of the body hot ; but the heat va- 
ries in different parts, the abdomen and palms of the hands 
being warmer than other parts. The thirst is very great, and 
increases with the increase of the fever ; the child drinking 
cold water with remarkable eagerness. The urine during this 
time undergoes a change, and is of a clear, orange colour. 
While asleep, the child tosses about in a very restless manner. 
In other instances the head appears to be the most affected part : 
drowsiness, stupor, and occasionally delirium appear, as the 
complication of the disease. At other times the complication 
appears to be in the pulmonary system, as manifested by in- 
creased and painful respiration and coughing. 

The paroxysms of fever go off with partial sweating, and 
the symptoms usually abate during the remissions, but do not 
wholly disappear; and when the fever is severe, the remissions 
are often almost entirely imperceptible. Although a partial 
moisture appears, the skin for the most part continues dry, even 
if cool. In proportion to the distinctness of the remissions, is 
the relief the child experiences from the peculiar symptoms of 
the disease, — the sleep becomes refreshing, and the child more 
lively. The exacerbations are milder and shorter, while the ap- 
petite returns ; and the secretions generally manifest an improved 
state of the system, the urine becoming turbid, and depositing 
a sediment of a reddish colour, while the stools exhibit a return 
of the healthy action of the liver ; a general moisture, also, takes 
place over the skin. The pulse loses its extreme frequency, 
but continues, through convalescence, somewhat above the na- 
tural standard. 

These are the usual symptoms of the disease, and include 
the three varieties described by Dr. Butter. Often, how- 
ever, they are not so strongly marked, and assume a less 
tangible form ; the fever being so slight as scarcely to attract 
attention, while the debility and protracted indisposition show 
the progress of a very serious affection, gradually wearing 



CIRCULATORY SYSTEM. 123 

out the vital energies of the system. The symptoms do not 
differ much from those above described, except that those 
of the abdominal viscera predominate, and the circulatory ex- 
citement is less active. The tongue is more furred, the abdo- 
men more prominent and hard, and the alvine evacuations show 
a greater derangement of the secretions, being very offensive 
and irregular in their appearance. There is an obstinate cos- 
tiveness at first, which is not of long duration, for a severe 
diarrhoea will occur at times, with every evidence of a great 
derangement of the secretory functions, the discharges being of 
a dark brown colour in most cases, but in some green, and in 
others red. In protracted cases the abdomen becomes tender, 
and streaks of blood are mixed with the faeces, while a severe 
tenesmus will often attend each evacuation. 

In this slow and indistinct variety, the urine preserves the 
white colour peculiar to it at the commencement of the disease, 
and it is supposed to indicate the presence of the earthy phos- 
phates, and is an evidence of a broken-down constitution. This 
appearance of the urine is described as very common by all 
the European writers. It is not of so invariable an occurrence 
in this country, for it would seem that the affection generally 
is of a more active nature here; and this symptom, with others, 
indicating a preternaturally bad condition, giving a peculiar 
type to the fever, is not here of so frequent occurrence as it is 
described to be in Europe. 

In general the disease is easily managed, and the prognosis is 
favourable, unless a complication takes place of congestion of 
the cerebral organs. When the remissions evidently become 
longer and the appetite returns, the child may then be consi- 
dered as convalescent. A lessening of the intervals, together 
with an increased swelling of the abdomen, may be regarded 
as affording an unfavourable prognosis. 

The most unfavourable symptom of infantile remittent fever 
is the cerebral affection, which almost invariably terminates in 
hydrocephalus. The diagnosis of this disease from the first 
stage of hydrocephalus is one of great difficulty ; and so closely 
do the diseases resemble each other, that they almost appear 
identical. One of the most remarkable signs of the cerebral 
affection, is the screaming and starting in the sleep, and the 
throwing of the hands over the head, and the constant attempt 
at bending the head backward. There is also a great intole- 
rance of light, and an evident affection of the intellect, together 
with strabismus. The child also swallows food without appa- 
rently discriminating its nature. In the disease now under con- 
sideration these signs of cerebral derangement do not exist ; 
there is no intolerance of light, no particular pain in the head, 



124 DISEASES OF CHILDREN. 

nor strabismus ; but, on the contrary, abdominal symptoms pre- 
vail, and the appetite is so entirely lost, that there is no disposi- 
tion left to take any kind of food. The alvine evacuations are 
very dark coloured and offensive, not having the odour of faeces, 
but of putrefaction. Sometimes convulsions arise, which may 
bear some resemblance to idiopathic cerebral disease ; but when 
they cease, the intellect of the child is perfectly restored. The 
state of the circulation, also, is different in these two diseases : 
the remittent fever having no distinct stages, the pulse is more 
uniform throughout, and never falling below the natural 
standard. 

Dr. Golis is very minute in the diagnosis of this disease, or 
worm fever, as it is denominated by him.* The disease, ac- 
cording to this distinguished writer, attacks children of a phleg- 
matic temperament with large bellies, and exhibits well marked 
remissions ; the face is swollen, and there is a general appear- 
ance of stupidity and sluggishness. In hydrocephalus all the 
distress is referred to the head, or rather alternates with the 
abdomen and pain in the limbs. He is unnecessarily minute in 
some of his descriptions, and the number of points of distinction 
rather tends to confuse than assist the diagnosis. The accurate 
designation is not of so much consequence as it would appear 
to be by the pains bestowed on it. The termination of remit- 
tent fever by effusion in the brain, being the probable termina- 
tion of the disease when fatal, it should be the duty of the phy- 
sician, in every instance, to keep in mind this tendency of all 
diseases, and especially the one in question, in children, and be 
ready to meet the symptoms of turgescence or inflammation of 
the brain when they arise. When this is constantly borne in 
mind, the necessity of an accurate diagnosis is rendered of little 
moment ; and, indeed, these minutiae are often of very little con- 
sequence, and tend too much to absorb the mind, and to draw it 
off from the consideration of the main object of medical prac- 
tice. It is sufficient for us, when there is great difficulty in ac- 
curately forming a diagnosis, to keep in view the strong and 
probable tendency of the disease ; to be on the watch for the 
appearance of such symptoms as give the disease its fatal cha- 
racter, and either anticipate them by the timely administration 
of remedies, or remove them, when they arise, by the energetic 
application of such means as the nature of the case demands. 

Morbid Anatomy and Pathology. — Dissections have fur- 
nished but little light on the morbid condition of the system in 
remittent fever : for on a fatal termination, the transition to the 



* A Treatise on Acute Hydrocephalus, etc., by Leopold Anthony Golis ; trans- 
lated by Robert Gooch, M. D. ; London, 1821, p. 46, et seq. 



CIRCULATORY SYSTEM. 125 

brain is the ordinary course cf the disease ; and effusion of 
serum in the ventricles will be all that will be found reman- 
ing of the disease, which at its commencement indicat ;d 
but little more than derangement of the primae vise. Pemberton 
discovered, in one case, the intestines very greatly distended, 
and the mesenteric glands much enlarged, without any signs 
of inflammatory action having existed in any part of the bow- 
els, or in any of the abdominal viscera, or without effusion in 
the abdominal cavity.* 

The occasional appearance of worms in the alvine evacua- 
tions of children affected with remittent fever, has led to the 
belief, that it was owing to their presence in the intestines that the 
peculiar symptoms of remittent fever occurred ; and even where 
their presence was not discovered in the faeces, the morbid 
secretions were regarded as dead and broken worms ; a notion 
which is still extensively popular. 

The idea of the presence of worms in the bowels as a cause 
of fever, was very prevalent during the last century, and was 
adopted by Baglivi to explain most of the diseases of children. 
Sauvages and Hoffman also entertained the like notions with 
respect to the causes of these febrile affections, such diseases 
being known by the name of febres verminosa?. 

The contrary opinion has been maintained by several distin- 
guished practitioners, and the errors which have so long pre- 
vailed, in considering the disease as dependent of the presence 
of parasitical animals, have been pointed out. Dr. Musgrove 
showed that these affections did not arise from worms, but 
from irritating matters, or saburra in the intestines.f Dr. 
Clark, also, particularly refers to the fact, that the remittent 
fever of children is rarely, if ever, cured by anthelmintics. J 

From the deep research and the philosophical acumen it dis- 
plays, Dr. Butter's treatise is the standard to which all reference 
is made at the present day. It is unquestionably the most com- 
plete essay on the subject, and the most in conformity with 
experience, both as to the ordinary appearance of the disease, 
and from the success of the treatment pursued by him, and 
which is the foundation of that adopted now. He does not 
regard worms as in any way essential to the disease, but refers 
all the symptoms which mark the disease, in almost every in- 
stance, to a debilitated state of the digestive organs, and to the 
accumulation of unhealthy secretion in the bowels, connected 



* A Practical Treatise on the Diseases of the Abdominal Viscera, by Christo- 
pher Robert Pemberton, M. D., F. R. S. ; Lond. 1806. 

t An Essay on the Nature and Cure of the (so called) Worm Fever; Lond. 1776. 
t Observations on Fever, etc., by John Clark, M. D. ; Lond. 1778. 



126 DISEASES OF CHILDREN. 

with the peculiarly sensitive condition of the infant state. Dr. 
Marsh* adopts a similar opinion, regarding the disease as arising 
from a deranged state of the gastric organ, and from a morbid 
action seated in the mucous membrane of these parts. 

This appears to be a very correct view of the disease, when 
the group of symptoms is taken into consideration ; when the 
morbid action is regarded at times as extending to the ap- 
pendages of the intestinal tube. 

The affection of the mucous membrane may exist in different 
degrees in various cases, which difference is not always to be 
ascertained. It cannot be regarded as being, in every instance, 
a state of inflammation of this membrane, as is usual to con- 
sider it in France, although such a condition will unquestion- 
ably arise during the progress of the disease. At first the 
affection of the mucous membrane is one of simple irritation, as 
I have frequently seen occurring suddenly from the ingestion 
of some irritating and insoluble substance ; the fever disappear- 
ing when it was removed. In one instance, where an infant 
suffered for some days without my being able satisfactorily to 
ascertain the cause, free and copious vomiting came to its re- 
lief, when a large mass of caseous matter was discharged, to 
the entire abatement of all the symptoms. This, and other 
instances, afford a satisfactory proof of the relation subsisting 
between infantile remittent fever and a simple irritation of the 
gastro-intestinal surface, without any inflammatory action being, 
in every instance, established. 

Besides irritation of the mucous membrane, the symptoms, 
in most instances, point out a depraved state of the secretions, 
which does not necessarily depend on the phlogosed state of 
the mucous membrane ; and the success of such measures, 
which will slightly alter or modify the secretory action of the 
gastric and intestinal mucous membrane, is much greater when 
there exists equivocal evidences of the inflamed state of the part, 
than the constant and sole employment of antiphlogistic and 
demulcent remedies. 

Dr. Joy considers it as a variety of gastric fever, modified 
by the irritable constitution of infancy, and closely allied to the 
febris pituitosa of Frank, f 

From an examination of the opinions of the various authors, 
compared with some amount of experience in the disease, re- 
mittent fever appears in general to be a symptomatic disorder, 
from derangement of the stomach and intestines, or of the 
appending viscera ; or from an irritative action, at first excited 



* Dublin Hosp. Reports, vol. iii. p. 316. 
t Cyclopaedia of Pract. Med., Art. Fever. 



CIRCULATORY SYSTEM. 127 

in the mucous membrane of these parts. It has been observed, 
that almost all fevers, connected with gastric derangement, as- 
sume a remittent character. This disposition, added to the irrita- 
ble constitution of young children, gives their febrile affection 
this peculiar type. When there exists any severe local inflam- 
mation, the fever is less likely to assume this character, from 
which it is evident that it is one more of irritation than inflam- 
mation. 

Treatment. — The treatment must, of course, be regulated 
according to the existence of the symptoms, from which we 
are to judge of the immediate cause of the fever. It is evident 
that in some cases it is a disease arising from simple irritation 
of the mucous surface of the stomach, from the presence of 
indigestible food, which ought to be promptly removed by some 
mild emetic. There is a difficulty often in ascertaining whether 
there exists this irritating cause alone, and independently of 
disordered action in the viscera. It may, however, be suspected, 
when it has arisen suddenly in children who have passed the 
period of lactation. In those at the breast, it is almost always a 
matter of difficulty to ascertain the existence of indigestible 
matters irritating the tender mucous membrane. This irrita- 
ting cause is often a long time gradually accumulating, and for 
the most part consists of the alteration of the milk, and the 
formation of a mass of cheesy matter, and until the removal of 
which, the symptoms of fever will obstinately continue. Where 
there is reason to believe the presence of irritating matter of 
this nature, a gentle emetic will be needed to remove it ; a 
measure which cannot be attended with hazard, where there 
exists no tenderness of the stomach on pressure, and when the 
other signs of gastric inflammation are wanting. Should a doubt 
exist on this point, the treatment may be commenced with a 
dose of castor oil, and the administration of enemata, with 
warm stupes to the abdomen. 

In this disease, as there usually is much disordered action of 
the liver, and an entire alteration of the secretory functions of 
the bowels generally, it will be necessary to give at first some 
more powerfully active remedies, which will produce an altered 
state of the secretions, especially of the liver. It is usual 
to prescribe calomel, in combination with jalap or rhubarb, or 
calomel alone, and promote its operation with an infusion of 
senna. Where the irritation is confined exclusively to the ab- 
domen, and the foul breath and furred tongue give proof of 
the congested state of the liver, and general derangement of 
the secretions, this course is unquestionably the most proper ; 
the operation of calomel with other purgatives being the most 
effectual, and the most prompt in the removal of the derange- 



128 DISEASES OF CHILDREN. 

ment on which the febrile action depends. Where, however, 
there is much fever, and especially a determination to the head, 
as hydrocephalus is almost an invariable termination of the dis- 
ease, it is thought by Dr. Hosack to be inadmissible, from the 
increased arterial excitement caused by the use of mercury.* 
His remarks appear to be more applicable to the disease, 
when caused by teething, or when it is complicated with this 
process. . The existence of hydrocephalus is much more pre- 
valent, according to the opinon of Blackall, Pemberton, and 
Willis, since the indiscriminate use of mercury in the affections 
of children. 

If the abdominal viscera are those most deranged, the use 
of mercury as a prompt cathartic can scarcely be dispensed 
with, for there is no article of the materia medica which exerts 
so general an action on the digestive organs, and which is so 
often followed by an improvement of their secretory functions. 
The employment of so active an agent is clearly indicated at 
the commencement, when the premonitory symptoms, — those of 
irregularity of the bowels, or total failure of the appetite, and 
a foetid state of the breath, — show an altered and morbid condi- 
tion of the secretions. Experience abundantly confirms the 
opinion here advanced, that it is on purgatives that we must rely 
at first ,where this morbid condition of the alvine discharges and 
urine, and swelling of the abdomen, are the most prominent 
symptoms ; for the gradual disappearance of the fever will 
almost invariably follow the use of mercurial purgatives under 
these circumstances. 

Dr. Hosack advises, in the place of calomel, an infusion of 
senna, combined with super-tartrate of potash and manna, where 
symptoms of hydrocephalus show themselves, as a purgative, 
which he has used with the most decided advantage. f To pre- 
vent this termination, he advises an open state of the bowels, 
and a free use of antimony, to unlock the surface of the body, 
together with warm bath and blisters, to create a new and rela- 
tively safe seat of irritation. 

The combination of calomel and antimony is highly useful 
in relieving the bowels, and controlling the febrile action when 
the latter runs high ; and may in some degree remove the ob- 
jections above made to the use of mercury at all in this disease. 

* Op. Cit., p. 332. 
t ^ Fol. Sennse, 

Potassse Sup. tart., 
Mannee, aa. § ss. 
Infuse in half a pint of boiling water. A wineglassful every two hours, according 
to the age of the child. 



CIRCULATORY SYSTEM. 129 

James's powder may therefore be advantageously given in 
this disease, combined with calomel, in the dose of one to five 
grains, or with the hydrargyrum c. creta, when there is a ten- 
dency to inordinate action of the bowels. This was a favour- 
ite course with Dr. Cheyne, in infantile remittent fever, espe- 
cially when the sensorial functions were affected, and hydroce- 
phalus apprehended. His practice was to prescribe a pill of 
calomel and antimonial powder three times a day, interposing 
between every two pills a moderate dose of a common purga- 
tive mixture. To persevere in the use of purgatives is not un- 
attended with danger, for the action of these articles them- 
selves becomes a source of irritation; our object being simply 
to remove the excessive accumulation of undigested matters 
and morbid secretions, and by stimulating the mucous mem- 
brane, excite it to a healthy action. Carried beyond this point, 
purgatives are decidedly injurious. Upon the appearance of 
severe local congestion, with high febrile excitement, blood- 
letting, either local or general, will form a necessary part of 
the treatment; and often a small quantity of blood-abstracted, 
on the appearance of the symptoms, will allay the fever and 
arrest the local disease. 

.It will be necessary, however, to preserve the bowels open, 
by the use of mild aperients, so that there may be two or three 
evacuations in the course of twenty-four hours. Dr. Butter 
was in the habit of using sulphate of potash for this purpose, or 
some of the other neutral salts, from their acting on the kidneys 
as well as on the bowels; while the febrile action is at the same 
time allayed, as he supposed, by their operation on the nervous 
system, especially by the sulphate of potash. Be this as it 
may, it is unquestionably an admirable medicine for children, 
as a deobstruent and cathartic. It appears to exercise a stimu- 
lating effect upon the liver and pancreas. Dr. Fordyce used it as 
a favourite alterative cathartic in visceral obstruction in children, 
where there existed a swollen abdomen and defective digestion. 
It is usually used in combination with rhubarb,* or it may 
be used in a solution, uncombined with any other cathartic, 
as used by Dr. Butter, in the proportion of a drachm to four 
ounces of sweetened water, of which a teaspoonful was given 
every hour, to a child of five years. When it had operated 
sufficiently on the bowels, he was in the habit of substituting 
the nitrate of potash ; and if a diarrhoea existed, five grains of 



* fy Potassae Sulph., gr. x. 
Pulv. Rhei., gr. v. 
Pulv. Sacchar. Alb., gr. x. M. 
Twice or thrice a day, for children above the age of six years, 

17 



130 DISEASES OF CHILDREN. 

the extract of conium was dissolved in four ounces of water, 
and taken in the course of twenty-four hours. The rule for 
giving the conium, was a grain daily for every year of the 
child's age. The advantage of this medicine is the combined 
effect it had, both of relieving the fever and controlling the 
diarrhoea. Sydenham's practice was, to give rhubarb in infu- 
sion, so as to act as a mild aperient, depending chiefly on this 
course for the management of the affection. 

When the disease is protracted, a continued use of hydrar- 
gyrum c. creta. may be necessary to restore the secretory func- 
tion of the liver, either combined with rhubarb, or used alter- 
nately with it, where it is deemed necessary, at the same time 
to procure an evacuation from the bowels every day. Where 
the contrary condition exists, the hydrargyrum c. creta may be 
used alone. 

In case evidences of inflammatory action of the mucous 
membrane appear, and the abdomen becomes tender on pres- 
sure, and the stools contain streaks of blood, mucilages in some 
form will be necessary, while the bowels are kept open by 
mucilaginous enemata, occasionally containing a few drops of 
laudanum, if the tenesmus be severe. 

In every case it will be necessary to examine the condition 
of the gums, and if they are swollen, to cut them freely down 
to the tooth ; this, together with some mild aperient, when the 
fever depends on this irritation, will remove all the symptoms. 

Where there is great debility and the disease is long conti- 
nued, it may become necessary to administer some tonic medi- 
cine ; and sulphate of quinine will be found the best for this 
purpose. But the early use of such remedies as has been ad- 
vised by some practitioners, can scarcely even be found of any 
advantage ; on the contrary, the symptoms will unquestionably 
be increased from the use of tonics and stimulants, if given 
shortly after the commencement of the disease, even if evacua- 
tions are used as preliminary steps in the treatment. 



NATURAL FUNCTIONS 



DIGESTIVE SYSTEM. 

PECULIARITIES OF THE DIGESTIVE SYSTEM. 

The digestive organs of man, in a state of infancy, are of 
great simplicity, when compared with their condition at any 
other period of life. They possess fewer parts than those of 
adults, as their office is of the simplest kind. The food of the 
infant not requiring mastication, there exist no teeth ; its sim- 
plicity rendering its mixture with the salivary fluid unnecessary. 
The glands supplying this fluid are, in early infancy, found to be 
of very minute size, and exercise no functional activity. When 
the teeth first appear, and during the period of dentition, these 
glands are in a state of great activity ; hence the quantity of 
saliva so often seen to flow in children that are teething, which, 
while it shows the simultaneous developement of the salivary 
glands and the appearance of teeth, affords also an outlet for 
the accumulation of blood, when there exist great irritation and 
congestion from increase of functional power. 

Man, at the earliest stage of his life, differs from his condi- 
tion in after life, in not being omnivorous. Nature has provided 
for him but one kind of food, and the slightest departure from 
the use of nature's nourishment would be to hazard the health 
;and life of the young being. Should it become necessary to 
■substitute any food for the mother's milk, that which has the 
greatest resemblance to it, both in consistence and quality, is the 
only one that can with safety be used. Milk is the sole food 
provided for his sustenance until the time when a change in his 
system takes place, when a new arrangement of his organi- 
zation enables him to receive nourishment from other substances. 

The appearance of the first teeth indicates the time when a 
change may be made in the nature and consistency of his diet, 
as they point out the ability of the child to use his efforts to se- 
parate the coherent particles of his food. Farinaceous articles 
may be made to form an addition to his aliment ; and in propor- 
tion to the appearance of the remainder of the teeth, its variety 
and solidity may be increased. 



132 DISEASES OF CHILDREN. 

The rudiments of the teeth are seen in the foetus of the second 
and third month, and are at first in the form of a double sac. 
A pulp of vascular and nervous matter is formed at the bottom 
of this sac, surrounded by a transparent fluid, which disappears 
as the pulp enlarges. Ossification first appears on the upper 
part of this pulpy substance about the end of the third month. 
The enamel is not secreted until some time afterwards. 

The alveoli are formed by the groove which runs along the 
edge of the jaw, and by its intersection, from the growth of osse- 
ous matter which extends from side to side. 

The crowns of the molars and incisors are generally com- 
pletely formed and ossified at the time of birth. The ossifica- 
tion of the roots does not occur until afterwards, by which pro- 
cess, and by the alteration of the form of the alveoli, the tooth 
is crowded upward, and absorption of the gum follows the pres- 
sure. The tooth at length makes its appearance above the gum. 

The teeth sometimes appear as early as the fourth month, 
while in some children that are of a delicate and feeble consti- 
tution, they do not show themselves until the end of a year ; and 
it has happened in some cases that the first tooth has not ap- 
peared until the fourteenth month. The process of teething is 
generally completed before the second year, but it has occa- 
sionally been protracted beyond that period, apparently depend- 
ing on the vigour of the child. 

As a general rule, however, the teeth first protrude about the 
sixth month, and appear in the following order, except in a few 
anomalous cases : The two middle incisors of the lower jaw, 
the two corresponding ones in the upper ; next the two lateral 
incisors of the lower jaw, which are followed by the two cor- 
responding ones in the upper jaw ; the two cospidati of the 
lower jaws then show themselves, succeeded by the two corres- 
ponding ones in the upper jaw ; and, lastly, the two molars in 
the same order as the preceding; and about the fourth to the 
sixth year appear four other molars, which remain permanent, 
making in all twenty. 

Although the teeth are generally developed in the order 
above stated, yet there have been many exceptions. Some- 
times the upper middle incisors, or lower lateral incisors, appear 
first; the cuspidati, and very rarely the molars, have been 
known to protrude first, and, in some cases, have been known 
to appear all at once. Pliny, Colombo, Marcellus Donatus, Van 
Swieten, and others, have given us instances of these anomalies. 
Louis XIV. was born with six teeth, and the celebrated orator, 
Mirabeau, had at birth two molars. On the other hand, there 
have been instances where they never appeared, and what is 
remarkable, instances of this have sometimes been hereditary. 



DIGESTIVE SYSTEM. 133 

The jaw of a child grows but little after the first set of teeth 
are completed, and the peculiar plump form of the face of in- 
fancy continues until the first permanent molars have appeared; 
and at the end of seven or eight years, the jaw begins to lose 
its circular appearance, and the face consequently assumes an 
elongated appearance. 

In children of a healthy constitution, dentition proceeds with- 
out much disturbance of the system ; it is strictly a process of 
developement, and therefore may, in the greatest number of 
cases, be left to the resources of nature. Heat and tumefac- 
tion are first perceived in the gums, when the teeth are about 
to appear. The first teeth, however, which are the incisors, very 
often show themselves without any previous manifestation of 
their approach. There is an instinctive desire for the child to 
press and bite the nipple, fingers, and almost everything pre- 
sented to its reach, probably from the itching attendant on the 
sanguineous turgescence of the part. Saliva flows abundantly 
in most cases, and greatly relieves the congestion of the parts 
surrounding the teeth. 

The second set of teeth give less disturbance to the system 
than the first, and the effects, from the protrusion of the teeth, 
are purely local. 

Children usually shed their teeth at about six or seven years 
of age; and the permanent set make their appearance in the fol- 
lowing order, occupying about five years in its completion: 
The middle incisors of the lower jaw, then those of the upper; 
next, the lateral incisors and anterior molars ; the lateral inci- 
sors of the upper jaw then show themselves ; the anterior 
bicuspides protrude about the ninth year, and the posterior, 
about a year afterwards. 

The cause of the shedding of the temporary teeth, is the dis- 
appearance of the branches of the artery supplying them with 
nutrition ; the roots and the sockets are then removed by absorp- 
tion. The whole of this is probably effected by the growth of 
the jaw, which at this period assumes a new shape, thus crowd- 
ing and obliterating the artery and nerve, and thereby obstruct- 
ing the flow of blood to them, causing them to perish for want 
of nutrition. 

The salivary glands are quite small until the period of den- 
tition, when they assume a considerable size, and secrete an 
abundance of fluid. They have a magnitude proportionate to 
the complexity of the digestion ; hence they are always smaller 
in carnivorous animals than in those living on vegetables; and 
during the infant state, when the food is remarkable for its 
simplicity, they are scarcely to be seen. During the period of 
youth these glands are fully developed, and, indeed, possess 



134 DISEASES OF CHILDREN. 

more than their ordinary supply of blood ; and for that reason 
are, at this period of life, more predisposed to disease. 

The muGous glands of the stomach and intestines are also 
very small before the eruption of the first teeth, agreeing in 
this respect with the salivary glands ; a general developement 
of every part concerned in digestion taking place at this period, 
either to furnish fluids for the assimilation of a new species of 
food, or to supply a lubricating fluid for the protection of the 
tender mucous surface from its irritation. 

At this time of life the mucous membrane of the entire in- 
testinal canal, including the fauces, pharynx and stomach, is 
covered with villi, and is highly vascular and sensitive. Hence 
the importance of confining the child to the mild and unirrita- 
ting food provided for it by nature. 

The small intestines are much longer in proportion than in 
the adult, and are about a third more in length, when compared 
with the entire length of the whole canal: the large intes- 
tines are longer in proportion to the small. The valvulse con- 
niventes are scarcely apparent, the vermiform process is very 
long, and the coecum is very largely developed. The coecum 
and colon do not present their depressions and prominences in 
so distinct a manner as in adults. 

The digestive passages are filled with a quantity of mucus 
during the first year, varying in colour and consistency in 
different parts of the intestinal canal. In the duodenum and 
jejunum it is thick, white, and very adherent. Sometimes it is 
coloured yellow by the bile. The large intestines are always 
at birth filled with thick, pitchy, deep green meconium. 

There remains in the intestines, after all the liquid matters 
have been removed, a layer of condensed mucus, adhering 
closely, like a plastering, to the mucous membrane, capable of 
being raised like a continuous membrane ; this will separate of 
itself, and is seen in the faeces in the form of small white floculi. 

The liver of an infant at birth fills almost a third of the ab- 
dominal cavity, descending even to the crest of the ilium. On 
the change of its circulation and obliteration of the umbilical 
vessels and ductus venosus, the left lobe diminishes, the vena 
portasis developed, and the secretion of bile occurs in abundance. 

The colour of the liver changes to a darker hue as life ad- 
vances ; and its size diminishes, when compared with the size of 
the individual ; but there have been instances where the size of 
the organ remained through life in the same proportions as in 
the fetus. 

The liver is nearly in the middle of the abdomen, with its 
anterior border near to the parietes. It ascends about the 
fifteenth year, so as to be entirely within the ribs when the child 
is recumbent. 



DIGESTIVE SYSTEM. 135 

The gall bladder is quite small at birth ; it soon grows, and 
contains green, bitter bile, which, however, is less viscid than 
at a more advanced age. 

There has been nothing worthy of remark observed in the 
spleen. No alterations in its form have been noticed, except 
such as may arise from disease. 

The anatomical characters of the abdominal viscera differ 
also with respect to their relative position, arising from the re- 
lations which the boundaries of the cavity have to each other. 
Thus, the distance from the sternum to the pelvis, in a new-born 
child, is nearly the third part of the length of the body, while in 
the adult it is about one fifth. The middle part of the abdomen, 
also, is more developed at the period when the distance is the 
greatest. The spine, also, being less curved at this period, it 
is deeper from the anterior to the posterior part. The pelvis 
being much smaller in children, and the sacrum being con- 
siderably curved forward, the capacity of the pelvis is com- 
paratively smaller than at a later period of life ; consequently 
the abdominal viscera are confined to the middle of the belly, 
until the growth of the pelvis and the enlargement of the ribs 
superiorly, which take place in the process of general de- 
velopement, increase the space for the lodgement of these 
viscera. 

The stomach reaches nearly to the navel, and lies almost 
perpendicularly, with its great curvature obliquely towards the 
left side, and the smaller towards the right. The omentum, 
therefore, is situated more towards the left ; a fact of some 
practical importance, for it might be mistaken for an obstruc- 
tion in the colon. 

The duodenum is almost entirely behind the stomach ; and 
the whole volume of the intestines is situated much higher than 
in the adult. The spleen, which in the adult is on the left side 
of the hypochondrium, can be distinctly felt under the short 
ribs, towards the middle of the abdomen.* 

After the first year, the organs of digestion do not differ greatly 
from their condition in the adult state ; and the p^-sence of teeth, 
and the activity of the salivary glands, show that the stomach 
may receive with advantage different kinds of food, which at 
an earlier period would have been productive of great disorder 
of the digestive organs. Although a variety of food may be 
used in early childhood, it is evident, from the condition of the 
organs for mastication, that food of the softest kind should still 
be used, that is to say, until after the completion of the eighth 

* Analekten ueber Kinderkrankheiten, vol. i. p. 51 ; Stuttgard. 



136 . DISEASES OP CHILDREN. 

year ; for until that period the power of mastication is but 
feeble. 

Digestion is a process of great activity in all children at 
every age — the constant growth of every part of the body de- 
manding a continual supply of nourishment. This process, how- 
ever, ceases to be so active in proportion as the child advances 
in age ; and the food becomes more stimulating, when the secre- 
tions more closely resemble those of the adult, and the fa;cal 
matters require to be less frequently voided, and are no longer 
passed independently of the will. 

The first process in digestion in the stomach of an infant is, 
the coagulation of the milk, as is seen to be the case when an 
infant throws up the milk shortly after sucking. The next is its 
solution, by the peculiar secretions of the stomach, liver, pan- 
creas, and intestines ; but of the process we have a very imper- 
fect knowledge, and are still unacquainted with the immediate 
part performed by the various glands. 

When considering the peculiarities of the physiology of chil- 
dren, and especially those which are connected with that part 
which performs so important an agency in their economy as 
digestion, we are struck with that peculiarity, which, at first 
sight, would appear to be a serious interruption to the process 
of digestion and nutrition — the vomiting which so frequently 
occurs in infants. We might be apt to consider it as a disease 
of the most serious character, connected as it is with the first 
step in the progress of the all-important function of assimilation — 
a function so intimately connected with the growth of the child. 
But when we watch more closely, we constantly see infants 
discharge the contents of their stomach without any inconve- 
nience resulting from it, even though the vomiting may be re- 
peated several times a day ; and far from exhibiting any evil 
which might be supposed to result from thus frequently vomit- 
ing their milk, they actually appear to thrive, and the most ro- 
bust children appear to be those most commonly affected with 
this species of vomiting. 

It is doubtless connected in some degree with great irrita- 
bility of the stomach, arising from the congested state of the 
mucous membrane of the whole intestinal canal, by which it is 
predisposed to act in relieving itself of the superabundance of 
aliment ; but from the absence of nausea, it would appear to 
depend on some other cause than either a condition of the mu- 
cous membrane of the stomach, or on an extrinsic exciting 
cause, the ordinary sources of vomiting, both in older children 
and adults. Professor Schultz,*' in an ingenious essay, refers 

* Hufeland's Journ., Marz, 1835. 



DIGESTIVE SYSTEM. 137 

it to the different form of the infant and adult stomach ; the 
former bearing a greater resemblance to that of carnivorous 
animals that vomit with great ease. 

Before stating in what this difference consists, it should be 
observed that his views, and which appear to be the most in 
accordance with the ordinary facts which occur in our every 
day experience, are adverse to the opinions of Boyle, Van 
Swieten, and to the deductions of Magendie, in later times, 
that the stomach is passive in vomiting, and that its evacuation 
is effected by the contraction of the abdominal muscles and 
diaphragm. If, as maintained by them, the action of these mus- 
cles was the only cause of vomiting, it ought to be purely volun- 
tary, which it is well known is not so, except in very rare 
cases ; and which, on that account, are regarded as curious in- 
stances of departure from the ordinary physiological condition 
of man. Vomiting, therefore, cannot be the act of these mus- 
cles alone. The movements of the stomach, like those of the 
intestines, are of a very gentle character, and are in strong 
contrast with the convulsive action of the powerful muscles, 
which are in full force during vomiting, especially during the 
experiments which are made to ascertain the action of the dif- 
ferent parts. On this account, probably, the French experi- 
menters concluded that it was perfectly at rest, and free from 
movement of any kind, there existing no convulsive motion in 
the stomach, its action being of the ordinary and almost imper- 
ceptible movement natural to it. These muscles, therefore, not 
being the cause of vomiting, the doctrine of the older physicians 
of the antiperistaltic motion of the digestive organs, comes into 
explain it. The existence of both these motions at one and the 
same time, is evident from the occasional effect of cathartic 
medicines, which, when about to produce the alvine evacuation, 
will also cause vomiting. Fcecal vomiting is also an evidence 
of the existence of an influence other than abdominal pressure, 
and proves the operation of the antiperistaltic motion from the 
large intestines, to the cardiac orifice of the stomach. 

The form of the infant's stomach explains the cause of the 
frequent and easy vomiting, it being much more conical than 
that of the adult, and resembles more the shape of the stomach 
of carnivorous animals. Professor Schultz remarks, that the 
oesophagus is inserted into the fundus at the left extremity, and 
at a distance from the pylorus. In the adult stomach the oeso- 
phagus is not inserted into the left extremity, but in the middle, 
between it and the pylorus, which is drawn towards the cardia, 
bringing both parts very near each other. The small curvature, 
therefore, in the adult, is very short, while in the infant it is com- 
paratively long, and the large curvature is but little developed : 

18 



138 DISEASES OF CHILDREN. 

this latter part in the adult is of great size, forming four fifths of 
the entire circumference. In the infant the fundus loses itself 
gradually in the pyloric portion ; in the adult they are separa- 
ted by a sort of contraction, more or less marked. 

From this arrangement of parts it will be seen how easy 
vomiting is effected in young children, as the food is equally 
propelled by the motion of the stomach to both extremities, 
and the situation of the oesophagus at one of them causes it 
readily to receive the food. On the contrary, from the great 
size of the large curvature in the adult stomach, the contents of 
this viscus are not in like manner equally propelled to both 
extremities, but are principally confined to that extended cavity, 
and are moved rather in a rotary manner ; the contraction 
above mentioned arresting them in one direction, and the situa- 
tion of the oesophagus preventing their passing in the other. 
Hence the difference in the vomiting of the adult and infant — in 
the latter easily effected, often without much general commotion ; 
in the former, not produced without the powerful aid of the 
diaphragm and abdominal muscles. This illustration receives 
confirmation from comparative anatomy ; dogs and cats, where 
the stomach is of a conical form, and bears a close resem- 
blance to that of an infant, vomit with great ease, and even 
throw up pieces of food, or a bone, if swallowed in an incon- 
venient manner. In the horse, rabbit, or hare, where the sto- 
mach is of the kind more resembling the stomach of an adult, 
with a large circular developement of the fundus, 'vomiting 
cannot be excited even with the strongest emetics. 

The cause of the difference in the form of the infant and the 
adult stomach, is doubtless the nature and quality of the food 
at these different periods of life. The cylindrical form con- 
tinues only while the child is fed on milk, a purely animal food ; 
and as it uses vegetable food the fundus greatly enlarges. Profes- 
sor Schultz has shown, in illustration of this, in another work,* 
that the stomach of carnivorous animals, dogs and cats, will 
assume a circular form, after they have been fed on potatoes, 
bread, and other similar vegetable articles ; but that it will re- 
tain its conical form if they are fed on animal food alone. The 
round stomach of domesticated carnivorous animals is never 
seen in wild animals of the same class. 

The reason of the greater developement of the fundus by the 
use of vegetable food, is owing to the greater difficulty of its 
digestion, and its long retention in the stomach before it is pro- 
pelled into the intestines. The food is moved in the stomach in 



* De Alimentorum Concoctione. 



DIGESTIVE SYSTEM. 139 

a rotarv manner, and the digested portion is gradually sepa- 
rated, while the undigested mass still requires the motion and 
agitation necessary to its perfect digestion. In carnivorous 
animals, the food, soon digested, passes directly towards the 
pylorus, and being in a smaller mass, and not requiring much 
agitation for the separation of its nutrient part, but little de- 
velopement of the fundus takes place. 

Nutrition is performed with great activity in all children, 
especially in infancy; for however defective may be the organs 
of relation, those which are essential to his nutrition and growth 
are in a state of perfection, at least so far as they are adapted 
to the food provided by nature, even at the earliest period of 
his life. The growth, through infancy and childhood, is evident 
both in the organs in particular, and in the body at lame. 
These changes exhibit themselves more to our senses in the 
organs of animal or relative life, than in those of the organic 
functions. These will be more particularly considered, when 
we come to consider the developementand growth of the cere- 
brospinal system. 

A male infant, at birth, weighs about one pound and a half 
more than the female, and is about an inch longer ; the growth 
of the female is less than that of the male, but she is more rapid 
in the developement of her organs. During the first year, the 
increase in stature is about eight inches ; it becomes less rapid 
towards the fourth year, but increases with great regularity 
after that period. 

The growth of children is a great source of disease, from the 
derangement of the balance of the various functions, so likely 
to ensue on the application of any cause which will arrest the 
developement of any part of the body, as is seen in almost every 
child. An unusual growth of the brain will cause great liveli- 
ness of character and intelligence, while the cause of this pre- 
cocity will predispose the child to convulsions, on the application 
of any cause which may derange the circulation in that organ. 
In others, the sanguineous and muscular systems preponderate. 
Here the face will be found florid, and the general frame vigor- 
ous; the child will be strong and active, and much disposed to 
inflammatory diseases or hemorrhages, arising from similar de- 
rangements in the capillary circulation. In others, again, where 
the lymphatic temperament prevails, obstructions in the growth 
and developement of these organs, will produce glandular 
swellings and ulcerations of the glands. 

As the child advances in life, the organic gradually cease to 
be the predominating organs, being replaced by those which 
constitute him an individual in the great family of intelligent 
creatures. 



140 DISEASES OF CHILDREN. 



SIGNS OF DISEASE FROM THE DIGESTIVE ORGANS. 

A white coating, of a curdy consistence, on the tongue of 
infants, denotes acidity of the primse viae ; indeed, all the phe- 
nomena exhibited by the secretions on this organ are sympa- 
thetic, and, in general, indicate diseases of the intestinal canal 
and lungs, from the membrane covering the tongue being a 
continuation of the mucous membrane of these organs. White 
points and aphthae are sometimes idiopathic, but in most cases 
show a deranged state of the stomach and intestines. An en- 
larged tongue may be occasioned by hypertrophy, inflammation 
or congestion. Swelling of the tongue in croup, measles, variola 
or pulmonary inflammations, is an unfavourable symptom. A soft, 
moist tongue, of the natural size, affords a favourable prognosis. 
A pale colour of this organ is a sign of great debility and sinking. 
A red tongue indicates a violent inflammation of the intestinal 
tube, and is mostly present in exanthematous diseases, especially 
in scarlatina. A tremulous motion of the tongue is an evidence 
of great nervous disturbance ; but if it occur in chorea, it ought 
not to be regarded as a dangerous sign. 

Grinding of the teeth often occurs in children without any dis- 
ease ; but if it occur in children who never evinced any such 
symptoms before — if it occur with starting from the sleep — if it 
be accompanied by great brightness of the eyes and flushing of 
the cheeks, there is reason to apprehend convulsions. It occurs 
in worms in the intestinal canal, and in cerebral affections. 

Increased secretion of saliva takes place in irritation near 
the parotid gland, or in the cavity of the mouth, in stomatitis, 
dentition, or tonsillitis. Diminution of saliva, with violent insa- 
tiable thirst after the continuation of acute diseases, is an unfa- 
vourable symptom. 

Redness of the throat is a sign of inflammation, both idiopathic 
and symptomatic, as in scarlatina, measles, and in chronic 
inflammation of the digestive or respiratory organs. Difficulty 
of swallowing arises from inflammation or swelling of the 
pharynx, oesophagus, tonsils, tongue, or parotid gland, ulcera- 
tions in these parts, or polypi in the pharynx and oesophagus. 
Coughing, after swallowing, indicates an inflammation of the 
larynx ; but this coughing should not be confounded with the 
strangulation and coughing arising in infants who receive their 
milk with more rapidity than they can swallow. 

When a young child drinks often, and with eagerness, and if 
the mouth be found to be hot and dry, it is very evident that a 
febrile condition of the system is present. Sometimes children 
drink with so great avidity that there is scarcely time given to 



DIGESTIVE SYSTEM. 141 

breathe; they are soon obliged to stop, respiring with a loud 
noise. Where there is an affection of the larynx, as before 
observed, a cough ensues ; and where the affection is severe, 
or extends to the lungs, the child cries ; and in those who have 
arrived at an age at which they can exercise their intellectual 
faculties, upon experiencing the distress produced by drinking, 
will obstinately refuse all drink. Insatiable thirst, in long con- 
tinued affections, is a very unfavourable sign : the agonizing 
eagerness with which a young child will seize and swallow 
any kind of drink in protracted affections, almost always pre- 
cedes dissolution. 

The continuance of a healthy appetite in chronic affections is 
a favourable symptom. When it is morbidly increased, it arises 
from some irritation in the stomach, but more especially from 
the presence of worms in the intestinal passages. An inordi- 
nate appetite, at the beginning of acute diseases, is an unfavour- 
able sign ; so is it after the subsidence of the active symptoms, 
if the strength of the child does not return. 

Loss of appetite, in acute diseases, is no unfavourable sign. If 
it occur in chronic affections, it is an evidence of great debility, 
and affords an unfavourable prognosis in children, where nour- 
ishment and growth are the most prominent and active functions 
of the system. Loss of appetite is a constant symptom, where 
disease of the digestive passages exists in the stomach, but less 
constant when the affection is in the lower intestines. 

Loathing of food, when arising from the condition of the 
mucous membrane of the stomach, is one of the usual pheno- 
mena of acute diseases, and is therefore not unfavourable. It 
is generally an attendant on a phlogosed state of the mucous 
membrane of the intestines, and affections of the pancreas, 
spleen, liver and mesenteric glands. There is occasionally 
loathing of food when there are worms in the intestinal tube, 
or inflammation, ulcerations and indurations of these organs. 
In chronic diseases, protracted loathing is indicative of organic 
changes in the digestive organs. 

Vomiting, in nursing infants, often arises from the stomach 
receiving more than it can contain, and which, if not thus rejected, 
would be a cause of indigestion and colic. Vomiting may also 
be a sign of affections situated in remote organs, as the head, 
kidneys, and neck of the bladder. It may also arise from acidity 
in the stomach, or from the presence of some acrid or other 
deleterious substance, and when painful, is an evidence of in- 
flammation of the oesophagus or stomach. In new-born infants 
it occurs in obliterations or obstructions in some parts of the 
oesophagus or intestinal canal. 

Vomiting is favourable if it follow simple repletion, and if 



142 DISEASES OF CHILDREN. 

the child, when old enough, expresses relief from the loathing 
and nausea, and if the fur on the tongue becomes loose, the skin 
moist, and pulse soft. 

Vomiting is unfavourable if there is no relief from the pre- 
vious oppression ; and if the epigastrium becomes painful, it is 
an evidence of the existence of inflammation. If protracted, of 
some organic change, or is symptomatic of hydrocephalus, or 
some remote affections. 

Young children not unfrequently vomit a caseous substance, 
apparently formed from their milk, when the previous symp- 
toms of distress, colic, fever, etc., disappear. Green substances 
vomited, not bile, are evidences of a gelatinous softening of the 
stomach, and is decidedly a bad symptom. 

The discharge of gas from the intestines occurs where the 
digestion is weakened ; when not discharged, it produces the 
phenomenon of flatulence, enlargement of the abdomen, and 
borborygmus. 

Children at the breast evacuate the bowels several times a 
day without the presence of disease ; but any irritation may 
increase the normal secretion, and give rise to purging, which is 
not always a sign of disease, as in the excitation of the functions 
of the muciparous follicles during the period of teething. On 
the other hand, it should be regarded as a serious affection, 
when occurring after the continuance of scarlatina, measles, or 
small-pox, or when, under any circumstances, it produces de- 
bility and emaciation. 

Tenesmus is a sign of disease in the rectum or colon ; haemor- 
rhoids, or worms, in the large intestines. 

Constipation may arise from defect in the biliary or intestinal 
secretion, or from inflammation of the intestines or of the brain, 
or from mechanical obstructions in the bowels, as scybala, 
conglomerations of worms, and intussusceptions. 

The alvine evacuations vary in a healthy state according to 
the food used. New-born children evacuate the dark substance 
known by the name of meconium. Sucking children pass a 
quantity of fasces, of the consistence of pap, and of a yellowish 
colour. The prevailing colour of the faeces in children, at all 
ages, is yellow. 

The substances discharged may be food, serum, mucus, bile, 
pus, blood, false membranes, and worms. If digestible sub- 
stances pass partly or not at all digested, it is a sign of inflam- 
mation in the intestinal tube, or of weak digestion. The dis- 
charges may be acid, frothy and highly offensive, as in cholera 
infantum, and are evidences of the deficiency of the biliary se- 
cretion. Thin fluid mucus is a sign of intestinal catarrh. It 
occurs in children affected with remittent fever. If it be viscid, 



DIGESTIVE SYSTEM. 143 

the prognosis is worse than when it is thin. Excess of bile 
occurs during the heat of summer, and is an evidence of great 
irritation of the liver or duodenum. The evacuation of blood 
is a sign of hyperoemia, irritation and inflammation, wounding 
or ulceration of the intestinal canal ; it is less unfavourable in 
little children than in adults. The passing of worms is an im- 
portant diagnostic and prognostic sign ; for if the symptoms of 
disease abate after their discharge, it is an evidence that they 
were caused by the worms, and the prognosis is favourable. 

The fulness of the abdomen is an important means of distin- 
guishing diseases of the intestinal canal from those of the brain 
in children ; and in them the fulness under the epigastrium, by 
the enlargement of the transverse colon, is very common, espe- 
cially in those of a scrofulous habit. A very inconsiderable dis- 
turbance in the functions of the intestines produces it in them, 
because their pelvis is small, and the liver large. 

If abdominal pain arise from peritoneal inflammation, slight 
pressure or mere contact produces a great aggravation ; but if 
paroxysms of pain arise from flatulence, they abate on pressure. 
When there is severe pain on pressure of the abdomen, nothing 
will divert the attention of a young child. The best method of 
ascertaining the actual existence of pain, is to raise the child 
from its bed, expose it to a strong light, and press with force on 
the abdomen ; and although the child may have cried violently 
before, its cries will cease, and its attention be fixed steadfastly 
on the light, if there exist no abdominal pain. If this sudden 
exposure to light fail in calming the child, we may then be satis- 
fied of its acute and continued suffering. 



DISEASES OF THE DIGESTIVE ORGANS. 
STOMATITIS.-INFLAMMATION OF THE MOUTH. 

The mucous membrane of the mouth is very liable to become 
inflamed in young children. It may be simply an erythematic 
form, without being followed by any result ; or may terminate 
in exudation of concrete mucus, ulceration, or gangrene. 

The first mentioned termination of stomatitis is an altered 
secretion of the part, having the appearance, most commonly, 
and always at the commencement, of white spots, resembling a 
small white flower, known in France by the name of muguet. 
Ulceration may occur in any part of the buccal mucous mem- 
brane, When it appears on the mucous follicles, it is the second 
stage of aphthae. Gangrene may be the termination of all the 
others, or maybe a distinct variety, commencing usually with an 
oedema of the part, and sanguineous congestion of the cellular 
tissue. 



144 DISEASES OF CHILDREN. 

Etiology. — This disease often arises from a state of con- 
gestion in the mucous membrane, at the earliest age, a condi- 
tion peculiar to the young infant at birth. The youngest 
children may therefore be affected with the simple variety, and 
that which is attended with a concrete exudation or altered 
secretion, or muguet; a term which has also been recently 
adopted in the English language. 

It may also be brought on by cold, any irritation in the mouth, 
as hot or stimulating food, too frequent use of the sucking bottle, 
but more especially from teething. Scarcely an infant passes 
through the period of teething, without suffering more or less 
from this affection. A deranged condition of the alimentary 
canal, accompanied by acidity, is almost always the cause of 
the aphthous and ulcerous variety of stomatitis ; and, indeed, the 
disease, in all its forms, appears connected with an irritated or 
phlogosed state of the other portions of the primse viae. 

The different forms of stomatitis have of late years attracted 
a great deal of attention in France, and a diversity of opinions 
prevails as to the nature and cause of these varieties. These will 
be considered below, under the head of pathology. It appears 
to prevail extensively, where many children are crowded 
together, and suffer from the necessary deterioration of the air ; 
it has on this account been thought contagious. Children, how- 
ever, who have not been affected with it, have not taken it even 
after drinking from the cup used by those who have laboured 
under the disease. 

When it extends to the cellular tissue of the cheek, and ter- 
minates in a total destruction of tissue, forming the affection 
known by the names of gangrenous erosion of the cheek, or 
cancrum oris, it becomes a very serious and fatal affection. 
The connection of the inflammation with an cedematous con- 
dition of the affected part, appears to cause a retention or stop- 
page of the blood in the capillary vessels, by which an indolent 
engorgement takes the place of inflammatory action. That this 
pressure is the cause of the gangrene, appears from the fact, 
that the most usual place of its appearance is where the pa- 
rietes of the mouth are most exposed to pressure, opposite the 
horizontal part of the jaw and dental arch. There exists in 
infants a predisposition to serous infiltrations, which renders 
them liable to this termination of stomatitis. It would appear 
to be more common in foreign hospitals than in this country, 
and is there exceedingly fatal, as indeed are all the inflamma- 
tory and ulcerous disorders of the mouth. This cedematous 
condition of the cellular tissue of young infants is peculiar to con- 
tinental Europe, and the infiltration proceeds to such an extent, 
as to produce an induration of the body. Where this gangrenous 



DIGESTIVE SYSTEM. 145 

affection occurs in older children, there is also a manifest tume- 
faction, with other symptoms, either local or general, of drop- 
sical effusions. 

SexMeiology. — In the simple or erythematic form of stomatitis, 
the mouth appears very red and hot ; sucking, mastication or 
deglutition are difficult, and often very painful ; and the pain 
arising from sucking, will often prevent the child from taking 
the breast. When it appears in teething children, an exceed- 
ingly profuse flow of saliva occurs. The inflammation spread- 
ing to the borders of the lips, forms ulcers, which, exciccating, 
produces a species of herpes. If the disease be very severe 
and protracted, small ulcers appear on different parts of the 
mucous lining of the mouth, on the frasnum of the tongue, at its 
base, internal surface of the cheek, and on the palatine arch, 
which have a yellowish white appearance, and around their 
edges the inflammation is very intense. A considerable degree 
of fever and restlessness, together with a derangement of the 
digestive organs, attend the local inflammation ; and when the 
disease is extensive, it is attended with more or less diarrhoea. 
The cry of the child indicates pain, without, however, any 
alteration in the tone. 

When the disease produces an exudation on the surface of 
the diseased membrane, it is known by the names of millet, 
white thrush, muguet, and is the form of disease designated 
by nosological writers by the title of aphtha lactantium. In 
this form the inflammation is very extensive, descending through- 
out the whole intestinal canal, when the disease is severe. This 
secretion varies much in appearance in different parts of the 
mouth; sometimes appearing in small white spots on the tongue, 
and again occupying other parts of the buccal mucous mem- 
brane, in the form of irregular patches. Sometimes, also, it will 
be spread over the entire surface of the back part of the mouth, 
in the form of a membrane. This affection of the mucous 
membrane, pouring out an altered, concrete secretion, must 
not be confounded with apthous ulcerations. It is only of late 
years that the distinction has been made, and the difference 
clearly ascertained. It may be known from aphthae by the 
curd-like appearance of the concretion, as if the affected part 
were dotted, or lined with cream or curd. When the disease 
increases, the concretion spreads, and unites in the form of 
a pellicle, constituting the confluent form. Vomiting and 
diarrhoea not unfrequently attend this disease, when it has con- 
tinued for a length of time, and are evidences of the progress 
of the inflammation to the other portions of the digestive pas- 
sages. 

When the inflammation more especially affects the muci- 

19 



146 DISEASES OF CHILDREN. 

parous follicles of the mouth, which may occur in those in 
whom they are prematurely developed at an early period, or 
at the time of dentition, when they first assume their peculiar 
functions, which is indeed the period of the affection of the 
follicles, a peculiar form of the inflammation, and subsequent 
degeneration, arises. This is what is usually known as aphthae. 
The disease shows itself under the form of small white points, 
with the appearance of a slightly prominent spot, of a darker 
colour, in the centre. They may appear distinct, and few in 
number, or spread over every part of the mouth ; and usually 
show themselves first near the lips and angle of the mouth. 

Sometimes the inflammation stops in the first stage, without 
proceeding to ulceration ; but if it persevere, a white purulent 
looking fluid is seen to issue from the centre, diffusing itself 
over the surrounding parts. 

When the ulceration proceeds, the aphtha? assume a new 
appearance ; the borders are prominent, the ulcer slightly cup- 
ped, and this ulceration secretes a pultaceous matter, which 
adheres for a while, and then becomes detached in the form of 
a small scab. When the aphthae are numerous, the ulcerations 
unite, run into each other, forming a confluent state of the 
disease. 

At the commencement of the ulceration, a bloody oozing 
not unfrequently takes place, which drying, forms a brown 
scab. Such are the local symptoms of aphthae ; and when the 
affection is mild, the child will experience but little, if any, dis- 
turbance of the general system. 

When, however, the eruption is extensive, there is often a 
great degree of drowsiness, sometimes with a slight fever, thirst 
and pain. A great restlessness usually accompanies the disease, 
while the acid eructations, and loose green stools, attest the 
extensive nature of the affection. There is no moisture of the 
skin, which is generally harsh and dry. The primae viae, how- 
ever, are more often affected than any other part, as the fre- 
quent vomiting, and thin, offensive alvine evacuations show. 
These discharges are often so acrid as to excoriate the anus 
and nates. As the disease advances the looseness of the 
bowels increases, and the child becomes much emaciated, and 
suffers greatly from severe languor and sinking. When aphthae 
become gangrenous, the surface is of a brownish hue, covered 
either with a hard or pultaceous eschar, while the parts sur- 
rounding them are of a dark modena hue, and much swollen. 
The edges of the ulcer appear as if burned, and emit a very 
offensive odour. The sufferings of the child prevent him from 
closing the mouth, and the saliva, mixed with fragments of the 
eschars, freely flows out; the face becomes pale, and the 



DIGESTIVE SYSTEM. 147 

pulse extremely feeble ; the child at last sinks in a complete 
state of exhaustion, from the combined effects of the profuse 
discharges from the bowels, and the state of inanition into 
which it falls, from the impossibility of swallowing food. 

The most fatal of these affections of the mouth is what has 
been known by the name of gangrenous erosion, or cancrum 
oris ; and has been described with great accuracy by Mr. 
Dease and Dr. Cuming, in Great Britain, and MM. Baron, 
Guersent, Isnard and Jadelot, in France. The best written 
treatise on this disease is that of M. Baron,* who has watched, 
with great carefulness, the commencement and progress of this 
affection. 

He has shown that there are two well-marked stages of the 
disease. It first appears in the form of an oedema of the cheek, 
a circumscribed, smooth tumefaction of the skin, in the centre 
of which appears a small hard body, on which there is sometimes 
a small red spot. In the second stage this small central spot soon 
ulcerates, and forms, on the internal surface of the cheek, a 
small eschar ; this ulcer spreads, and all the soft parts become 
successively disorganized ; the periosteum separates from the 
bone, leaving it exposed, while the remains of the gums and 
sides of the mouth, with bloody exudations, exhaling a foetid 
odour, flow out with the saliva. These are its distinguishing 
symptoms. The others, such as sinking, vomiting, restlessness, 
pain, diarrhoea, are common to all forms of stomatitis, when 
pursuing its uninterrupted course to a fatal termination. 

From this account of the symptoms attending stomatitis, the 
various forms of the affection may be readily distinguished. 
The only difficulty on this point may arise between a severe 
exudatory stomatitis and the aphthous affection; the latter, 
however, may be known from the manner of its commencing, 
always appearing in spots, by its uniformly preserving its cir- 
cular form, and by being always surrounded by a red circle. 
The aphthae, before they become inflamed, may generally be 
seen and always felt, as M. Billard asserts. 

Morbid Anatomy. — The anatomical nature of the simple 
form of stomatitis is evident from the symptoms detailed above. 
It consists of a sanguineous congestion of the mucous mem- 
brane, and is often attended with a similar condition of the sto- 
mach and intestinal canal. 

The ulcers that form from the erythematic inflammation of the 
mucous membrane, appear to be a softening of the mucous 
membrane. A sort of pulpy degeneration of its texture, accord- 
ing to M. Denis, takes place in the palate about the medium line. 

• V. Bulletins de la Faculty de Medecine, 1816. 



14S DISEASES OP CHILDREN. 

If this pulp be raised, the bottom of the ulcer is found to be the 
healthy bone. 

The exudation following the inflammation of the mouth, has 
received, within a few years, a great deal of attention on the 
part of the French pathologists ; and it is only of late years 
that its true pathology has been ascertained, and the line of 
distinction drawn between this form of disease and the aphthous 
affection of the mouth. The works of Breschet, Guersent, 
Lelut and Billard, contain a clear account of the nature of this 
pseudo-membranous formation. Guersent* considers muguet 
as a local affection, capable of affecting almost any part of the 
intestinal tube. M. Denisf also considers it in the same light. 
ValleixJ entertains the same view of it, and that its seat is 
throughout the entire digestive passages, the affection of the 
mouth being merely a part of the general disease. M. Billard 
regards it as stomatitis, with altered secretion. There is reason 
for believing that like all other affections of the mucous cover- 
ing of the mouth, the disease may be transmitted by continuity 
of membrane ; and this is precisely what takes place, for it not 
unfrequently appears around the gums, edges of the tongue, 
etc., extending ultimately to the pharynx and oesophagus. 

A sanguineous congestion always attends the disease in ques- 
tion ; points or shreds of a white concrete mucus is spread 
over every part of the interior of the mouth, and always on- 
the surface of the epithelium. The varieties of form have re- 
ference to the seat ; that which appears in points is at the ex- 
tremity of the tongue. The cheeks are covered with lamina? ; 
and that which assumes the membranous appearance, occurs at 
the velum and base of the tongue : the villosities of the mucous 
membrane being longer and less fine at these parts, the mucus 
is secreted in the form of a membrane. M. Lelut, after a 
number of experiments on the nature of the membrane, arrives 
at the opinion, that it bears a great resemblance to the buff of 
the blood and false membrane of croup ; hence it w T ould appear, 
that the inflammation had rendered the mucous secretion more 
rich in fibrin. 

When the inflammation has extended to the pharynx, tonsils, 
and parts adjacent, an exudation of a very dangerous nature 
occurs, known by the name of diphtheritis ; its danger arises 
from the narrowness of these passages in children. This exu- 
dation is of the nature of lymph, and may be at times removed 
from the part over which it is spread, without leaving any de- 

* Diet, de MeU, in 21 vols., art. Muguet. 

t Recherches d'Anat. etde Physiolog. Path, sur plusieurs Mai. des Enf., 1836, 
p. 106. 
t Clinique des Mai. des Enf. ; Paris, 1838, p. 20& 



DIGESTIVE SYSTEM. 149 

struction of parts beneath, even though the pellicle itself be in a 
state of decomposition. In many instances, however, where 
the disease is rapid, the parts beneath have been found in a 
state of gangrene and disorganization. 

The precise nature of aphthse has been the subject of much 
investigation ; and from the time of Bcerhaave to that of Bichat, 
much genius has been displayed in the endeavour to ascertain 
their precise seat and nature. Callisen has described them as 
small tumors, arising from the affection of the mucous glands. 
Gardien regards them as vesicles ; and Billard considers 
them as a morbid developement of the muciparous follicles of 
the mouth, sometimes in a state of simple tumefaction, at other 
times in a state of ulceration. 

In fatal cases of aphthae, the inflammation not unfrequently 
prevails through the whole intestinal canal, while the aphthous 
affection, in some cases, extends only through the oesophagus. 
Small superficial ulcerations have been found in various parts 
of the intestinal passages. Excoriations exist about the arms, 
caused by the acrid nature of the discharges. 

The pathology of the ordinary affections of the mouth which 
terminate in gangrene, is detailed in the symptoms of these 
affections ; for the actual anatomical disorganization is through 
life the subject of every day's inspection, and therefore needs 
not to be repeated here. A few words, however. . jecessary, 
with respect to the nature of the gangrenous erosion of the 
cheek, and the pathological condition connected with it. 

The subjects of this disease are generally in an enfeebled 
condition, often from the effects of previous disease, as inter- 
mittent or remittent fever, and, as is not unfrequently the case, 
as a sequela of these diseases, the patients are in a dropsical 
condition. The local affection scarcely appears to be of an 
inflammatory nature, while a swelling and apparent congestion 
exist , in the forming stage, and the part actually appears paler 
than natural, and no increase of heat is perceptible. An oede- 
ma of the part is doubtless one of the causes of the rapid dis- 
organization and sloughing. 

In children advanced beyond the period of teething, gangre- 
nous affections of the mouth appear to depend on diseases of 
the teeth, their fangs, or the periosteum covering their roots or 
sockets. Where great debility of the system prevails, and the 
still growing teeth press on the periosteum, a membrane pos- 
sessing but little vitality, it is unable to bear the additional exten- 
sion it undergoes across the unyielding bone. The blood, 
consequently, ceases to circulate in it, and it dies. Ulceration 
of the adjacent parts follows ; and the periosteum having scarcely 
any sensibility, the sympathies of the other parts of the system 



150 DISEASES OF CHILDREN. 

are but little interested, until an extensive portion of the mucous 
membrane of the mouth or mass of cellular substance becomes 
affected. This explains the rapid and extensive penetration 
of the ulcer along the roots of the teeth, and the destruction of 
the bone.* 

The same affection is also at times very extensive in its pro- 
gress, involving the bones of the face. Cases of this kind occurred 
a few years since in the New- York Alms House, an account of 
which has been given by Dr. Sherrill, now of Hyde Park, 
Dutchess County. t 

Treatment. — The treatment of stomatitis, in its various forms, 
may be divided into local and general. 

Local Treatment. — The milder form of this disease, in its 
different varieties, will often require no other treatment than 
such remedies as may be applied directly to the seat of the 
affection. In the simple erythematic inflammation, mild mucila- 
ginous applications are the most rational and the most effica- 
cious ; and nothing can be more injurious than the use of irrita- 
ting and stimulating agents, which not unfrequently are resorted 
to at the very commencement of the disease. Various muci- 
lages have been used, such as a mixture of cream and the white 
of an egg. A piece of the bark of slippery elm, (ulmus fulva,) 
saturated with simple syrup, may be given to the child to chew, 
or it may be held in the mouth by the nurse ; or a decoction 
of flaxseed, or powdered gum arabic, may be used for the 
same purpose.J The latter substance, in fine powder, intro- 
duced in small quantities into the mouth, I have found to be the 
remedy the easiest of application, and the most efficacious for 
the disease, the adhesive nature of the gum causing it to be 
retained in the mouth much longer than any other substance. 
It may sometimes happen that the violence of the inflammation 
may require leeches to be applied ; when these are necessary, 
the angle of the jaw, or about the part near the inferior portion 
of the ear, will be the best place for their application. When 
an enlargement of the submaxillary glands accompanies these 
affections of the mouth, they should be applied in the vicinity 
of these glands. Some caution, however, should be used, in 
applying leeches in those cases where there is much constitu- 
tional debility, or where the affection has arisen after other 
protracted diseases. 

* V. Dr. Coates, in N. A. Med. and Phys. Journal, 1826. 

t On Caries of the Jaws of Children, etc., by Hunting Sherrill, M. D., Physician 
to the NY. Aims-House; New- York, 1834. 
t Ifc Mist. Acaciae, 
Albuminis ovi., 

Syrupi, aa. partes sequales. M. 
Lmctus for local inflammation about the mouth. 



DIGESTIVE SYSTEM. 151 

Should ulcers appear, or the exudation of altered mucus 
show itself, some stimulating applications will be necessary to 
alter the action of the capillaries of the affected part. In the 
former case these applications may be made directly on the 
appearance of the ulcer ; in the latter, not until the inflamma- 
tion has been in some measure allayed. Borax has for a long 
time been a highly popular remedy, combined, in a fine powder, 
with an equal quantity of white sugar, which may be put into 
the mouth dry ; or a wash made of a drachm of honey of borax 
and an ounce of water, applied by means of a soft piece of 
rag, or a camel's hair pencil. Alum has also been used for the 
same purpose, and is certainly a very useful remedy, and has 
appeared more successful than the more popular one just men- 
tioned.* The cutting of the gums should never be neglected, 
if there are indications of the protrusion of the teeth ; and 
scarifying the gums is necessary in that form which accom- 
panies the process of dentition, known by the tumefaction and 
sponginess of the gums and decaying of the teeth. The mouth, 
in this affection, should also be freely washed with a decoction 
of cinchona or oak bark. These astringent washes, also, are 
often all that is required to treat the slight ulcerations of the 
mouth: a small piece of alum should be dissolved in the infusion, 
to increase the efficiency of these means ; and, in severe cases, 
chloride of soda, in the proportion of half a drachm to three 
ounces of water, will be found useful. 

In the ulcerated mouth, and in aphthae, properly so called — 
the second stage of the morbid developement of the follicular 
apparatus of the mouth — much the same treatment will be 
necessary; and in obstinate cases, a change in the remedies 
applied will often be found necessary. Dr. Dewees speaks of 
the benefit derived from Armenian bole, mixed with powdered 
loaf sugar, and sprinkled in the mouth. Sulphate of copper, 
however, is the most powerful and useful stimulant, and should 
be applied in the proportion often grains to an ounce of water, 
with a fine camel's hair pencil. According to the strength of 
the solution, it is either a powerful stimulant or an escharotic, 
and therefore is applicable to every form and variety of ulcer- 
ation. Nitrate of silver is also a very efficacious means of 
arresting the extension of the ulcers ; and in the case of con- 
fluent ulcerations, may be applied in solution over every part 
of the diseased surface. In distinct aphtha? the solid form is 



* # Mellis Ross, §ij. , # Alurrrnis, 3j.— 3ij. 

•Aluminis, 5j. Aquas Rosee, §ij. 

Tinct. Myrrhse, 5ss. M. Solve. M. 

To be applied to the ulcers of the mouth. I 



152 DISEASES OF CHILDREN. 

the best, being used to touch the ulcers, which will quickly 
yield to this remedy. Chloride of soda has been recommended 
by M. Guersent ; it is more particularly applicable when 
sloughing has ensued, and the decomposition of parts has com- 
menced, which may be known by the foetid odour of the breath. 
In these instances of sloughing, the most powerful escharotics 
will be found necessary for the arresting of the disease, by the 
destruction of the part ; and the muriate of antimony is that 
which has been found the most efficacious. Muriatic acid has 
also been used in severe cases, even in an undiluted state ; but 
it is not so safe as other escharotics, from the difficulty of con- 
trolling its action. In the use of all these stimulating and escha- 
rotic applications, their effects should be carefully watched, that 
an increase of inflammation may not be caused by a too per- 
severing use of them. They may from time to time be suspended, 
and mucilages substituted, when much irritation or inflam- 
mation is present. They may be applied with more safety by 
means of a small glass capillary tube, immersing one end in the 
acid, and drawing up one or two drops, and then depositing 
them on the surface of the affected part. On the separation of 
the eschar thus formed, it would not be proper to repeat the 
same application, as the part would be left in a state of extreme 
irritability. A pencil of nitrate of silver w T ill be found the best 
escharotic for subsequent use, as it can be repeatedly used 
without causing an increase of the inflammation. 

That form of ulceration which is known by the name of gan- 
grenous ulceration, or gangrenous erosion of the cheek, and 
which consists of a tumefaction of the affected part, and its sub- 
sequent alteration, softening and destruction, demands an 
especial notice ; for it can hardly be classed with any of the 
preceding forms of stomatitis, inasmuch as it appears to depend 
for its peculiarity more on an oedema of the part, and the con- 
gestion of the capillaries, than an active inflammation. MM. 
Baron and Guersent have written largely on this subject. The 
former, especially, has examined closely into its nature, and 
caused the treatment in the different stages of the disease 
to be more strictly founded on pathological principles. 

In the forming stage, that of infiltration, the application of 
stimulating frictions to excite the absorbent vessels will be 
found necessary. Liniment of hartshorn may be used for this 
purpose, or a solution of muriate of ammonia, applied to the 
cheek by means of pledgets saturated with the solution. Upon 
the appearance of the least ulceration, or should a violet spot 
show itself on the cheek, more active measures will be neces- 
sary; and muriate of soda, muriatic acid and honey, caustic, 
potash, and muriate of antimony, have been employed by various 



DIGESTIVE SYSTEM. 153 

practitioners with success, according to the representations of 
the French physicians. The actual cautery, also, in the hands 
of MM. Jadelot, Guersent and Baron, it is said, has been of 
eminent service in the gangrenous stage of this affection ; but 
we may judge of the success of these means, and especially 
of the latter, by the candid acknowledgment of M. Marjolin:* 
" almost all children," says he, "affected with this disease in the 
Parisian hospitals, die." He also uses the bistoury and scissors 
to remove the thick sloughs. Dr. Burns used chloride of lime, 
nitrate of silver, carrot or yeast poultice. Nitric acid, also, has 
been employed with advantage in severe cases of gangrene. 

Sulphate of copper, however, is the remedy which has suc- 
ceeded beyond all others in changing the character of the 
ulcers, and causing a rapid healing of the part. It has the 
advantage over actual cautery, from the facility with which it 
may be applied to every portion of the disease ; and every part 
ought to be brought under the influence of the application. The 
solution should be made strong, in the proportion of two 
drachms to a four ounce mixture. f 

General Treatment. — In every form of stomatitis, a greater 
or less derangement of the primse vise exists ; it will, therefore, 
be necessary to pay some attention to the condition of the 
stomach and bowels. It ought, in the first place, to be the care 
of the physician to ascertain whether there exists any inflam- 
matory action in the mucous membrane of these parts, before 
the administration of active purgatives or emetics. Often, 
however, the existence of a high state of irritability, or slight 
inflammation, has its cause in the presence of acrid or acid in- 
digestible matters, which ought to be removed by appropriate 
means ; and it not unfrequently happens that the disease has 
been entirely arrested by the administration of some mild pur- 
gative. Castor oil or magnesia, according to the prevailing 
indication, are the medicines most applicable to the condition 
of the stomach and bowels, when it is deemed necessary to 
administer aperients ; the occasional use, also, of mild purgative 
remedies, when not contra-indicated, will also be necessary 
throughout the disease, to preserve the secretory apparatus of 
the intestines in a state of functional activity. J A. full dose of 



* Art. Gang, de la Bouche, Diet, de Med. 

t Vide Dr. Coates, in N. A. Med. and Surg. Journ., 1826. 



t fy Pulv. Rhei., 3j. 
Magnesise, 3ij. 
Pulv. Acaciae, gr. x. M. 
Dose from three to four grains every 
third hour, to a child of six months old. 
Six to ten grains, for one a year old. 

20 



^c Infus. Khei., fss. 
Sulph. Potassae, 3ij. 
Tinct. Cinnamon, §ss. 
Syrupi Sennse, 3iv. M. 
One to two drachms every three hours. 



154 



DISEASES OF CHILDREN. 



calomel, when the bowels are obstinately constipated and 
tumefied, may be required. When the breath is offensive, with 
nausea, a mild emetic, such as ipecacuanha, will often remove 
the irritating cause of the affection. 

In case of tenderness of the abdomen, indicating inflamma- 
tory action in the bowels, or when the stools are streaked with 
blood, warm baths and fomentations to the abdomen will be 
necessary, while active purgatives should be avoided ; muci- 
lages ought, under these circumstances, to be freely used. 
The warm bath will also be serviceable when there exists much 
general heat of the body ; and if accompanied by restlessness, 
anodynes,* judiciously administered, are of singular efficacy 
in calming the nervous commotion of young children, and 
greatly add to the diaphoretic effect of other remedies, and 
materially aid in the restoration of the lost balance of circu- 
lation. One of the best forms in which an anodyne can be 
given, is Dover's powder. Should there exist much acidity, 
and especially if accompanied with diarrhoea, and absence of 
abdominal pain on pressure, prepared chalk, combined with the 
pulv. ipecac, c, before mentioned, should be given every two 
or three hours, to arrest the alvine discharges. 

Dr. Eberlef says, that in obstinate cases of aphtha?, he has 
found great benefit to arise from the use of a solution of nitrate 
of silver, internally administered, in the proportion of a grain 
to two ounces of water, a teaspoonful to be administered to 
infants between two and six months old, every four hours. 
Powdered borax has also been given in similar cases with 
advantage. It is extensively employed in Germany in the treat- 
ment of infantile diseases, in cases of acidity and aphthae. It 
is given in the form of a linctus, made with the honey of roses ; 
half a drachm to one drachm of the former to two ounces of 
the latter ; a teaspoonful four times a day. Richter advises it, 
combined with magnesia. 

Mercury has been used, it is said, with good effect in these 
affections; and it has been recommended on the ground that 
the constitutional change resulting from its use will not be con- 
tracted by the affections of the salivary glands or gums. It 
must, however, be a hazardous remedy, and one which we 
should not be disposed to try in any form of stomatitis, espe- 



* fy Aquee Destil., §j. 
Mist. Acaciae, §ss. 
Syrupi. Simp., §ss. 
Tinct. Opii. Guttam. M. 
Dose, a teaspoonful repeated every 
half hour, till rest be procured. Double 
that quantity after a month. 



$: Aq. Fceniculi., fj. 

Tinct. Opii, gt. vi. — viij. 
Syrup. Aurantii, 3vj. M. 
A teaspoonful every hour, to a child 
of two years. 

+ Op. Cit., p. 179. 



DIGESTIVE SYSTEM. 



155 



cially after the period when the salivary glands have begun to 
act. 

On the appearance of sloughing, great prostration of strength 
ensues, and it will be necessary to resort to stimulants to sustain 
the strength, as wine whey, or ammonia. Tonics, also, become 
necessary, and at the head of this class of remedies stands 
quinine.* The tartrate of quinine, especially, has been recom- 
mended in cases of gangrene. Chlorine, in the form of chlo- 
ride of soda, has also been used as a stimulant, in sinking cases 
of aphthae and gangrenous affections of the mouth. Dr. E vanson 
mentions, that the use of iodine has been attended with success ; 
the manner of its exhibition and dose he does not mention. The 
subjoined formula, however, may be used.f 

Where it is necessary to remove the irritating and putrid 
matters swallowed, and to keep the bowels free in the sloughing 
stage of these affections, spiced or aromatic syrup of rhubarb 
will be found peculiarly appropriate, carefully watching against 
a hypercatharsis. In the state of debility and manifest loss of 
vital powers, after the gangrene has commenced, it may some- 
times be necessary to have recourse to stimulants, to rally the 
receding powers, and restore energy to the action of the heart.J 

The child should be kept exclusively to the breast, if it be 
not weaned. The mildest and least irritating food must be the 
only kind allowed to those artificially fed, or who have passed 
the period of nursing. Arrow-root, soft boiled rice, sago, or 
tapioca, are the most proper vegetable aliments ; and soft boiled 
eggs, calves' feet jelly, chicken broth, may be required, when 
a state of debility and sinking demands articles more abounding 
in nutrient qualities. 

TONGUE-TIE. 

The frsenum of the tongue sometimes extends quite to the 
extremity, or is so short as to interfere with the proper move- 
ments of that member. When this is found to be the case, and 
the child sucks with difficulty, the division of the membrane 



* fy Gtuinoe Sulph., gr. ij. 

Acid, Sulph. Aromatic, gtts. xvi. 
Syrup. Caryophill., §ss. 
Aquae Destill., § iss. M. 
S. Dose, 1 to *2 drachms thrice a day. 
t Ifc Iodinii, gr. v. 

Potass. Hydriod., 3ss. 
Aq. Destil., § ij. M. 
To children under seven years 2 drops 
twice a day, gradually increased to 5 
drops ; to children above seven, the dose 
may be progressively advanced to 16 
drops, in a little water. 



t fy Aquae Menthae, f iss. 

Sp. Ammon. Arom., 3ss. 

Sp. iEtheris Nitnci., gt. xij. 

Sp. Lavand. C, 3j. 

Syrup. Caryoph., fss M. 
Dose, a teaspoonful every two hours. 

Ifc Ammonia? Sesquicarb., 3ss. 
Aq. Menth. Pip., gvij. 
Syrup. Aurant., §ss. M. 
A tablespoonful occasionally. 



156 DISEASES OF CHILDREN. 

must be made ; an operation of great simplicity, although not free 
from danger, as serious hemorrhages have occurred from a 
wounding of the blood-vessels beneath the tongue, and from the 
tongue passing back on being loosened, so as to close the glottis. 
The best method of performing this operation, is to place the 
fore and middle fingers of the left hand beneath the tongue, on 
each side of the fraenum. and with a single stroke, with a sharp 
gum lancet or probe pointed scissors, in a downward direction, 
divide the fraenum. It is very common for nurses and mothers 
to request the attention of the physician to this subject when 
no interference is necessary, which may be known by the child 
being able to suck. 

MORBID DENTITION. 

Some philosophical writers on medicine do not allow dentition 
to enter into the number of diseases; but it is evident to all 
practical men, that irritation, inflammation, fever and other affec- 
tions, both local and general, not unfrequently attend this pro- 
cess. Although the operations of nature are conducted in so 
complete a manner as to make it unnecessary and unwise to 
interfere in the natural developement of parts, yet the inflam- 
mation, fever, and other morbid phenomena^ dependent on the 
eruption of the teeth, fraught as they are with great evil in the 
tender and susceptible system of infants, demand for them a 
distinct notice. Dentition is not itself a disease ; yet the injudi- 
cious feeding of infants, impure air, and other circumstances 
attending an artificial mode of life, will render the process one 
of difficulty and danger.* 

Etiology. — The morbid phenomena attending teething have 
their origin in the pressure of the growing teeth on the peri- 
osteum and gums ; depending in a great degree on the peculiar 
temperament of the infant. Some are affected with inflamma- 
tory, and others simply with a nervous excitement. This pres- 
sure is not in the same degree through the whole course of 
teething. At first, before the teeth have pressed much on the 

* The following fact, related by M. Robert, in his Traite des Principaux Objets 
de Medicine, is an instructive illustration of the effects of morbid dentition. A 
child, after having suffered greatly from teething, died, as it was supposed, and was 
duly laid out in its burial clothes. M. Lemonnier, having some business at the 
house of the nurse where the child had been during its last sickness, learned the 
facts above stated, and being curious to ascertain the condition of the alveoli in an 
instance where the teeth had not protruded, requested and obtained permission to 
make an autopsical examination. He commenced by an extensive and deep incis- 
ion into the gum ; and while he was preparing to extend his investigations, he ob- 
served the child open its eyes, and give other signs of life. He immediately applied 
such remedies as the nature of the case required ; stripped off its shroud, applied 
other and warmer covering, and with care and good nursing the teeth soon appeared, 
and the child ultimately recovered its health. 



DIGESTIVE SYSTEM. 157 

gum, and while they are passing from the pulpy to the bony 
consistency, the pressure is principally by the root shooting 
inward ; this occurs about the third or fourth month of 
infancy. At a little later period, about the sixth month, the 
pressure is exerted on the gum, and the peculiar symptoms of 
dentition present themselves. The pressure is also made by 
the rising tooth on the membranous expansion over the tooth. 
From these irritations, distant organs are also sympathetically 
affected. On this account, the period of teething is the most 
critical of childhood, and the diseases with which children are 
attacked at this time, are rendered more dangerous from the 
constitutional irritation produced by teething. This extensive 
sympathy arises from the extremely irritable state of the system 
in infancy ; for at a later period, when larger teeth are cut, but 
comparatively little constitutional disturbance ensues. 

One of the causes of painful and morbid dentition, is the 
unequal and disproportionate developement of the teeth and 
jaw ; their sudden and simultaneous appearance also becomes 
a source of disease, from the united pressure of many teeth, 
and the great afflux of blood it occasions. 

The conditions of the system predisposing to constitutional 
disturbance from teething, are those which are connected with 
an irritable state of the nervous system, from whatever cause 
it may arise. The younger, therefore, the child is, the more 
will it be likely to be affected with serious disturbance during 
the process of teething ; and all feeble and delicate children 
are more affected in this process than those who possess more 
stamina. Such infants often suffer from protracted diarrhoea, 
and die, wasted with marasmus. This class of patients are 
found among those who suffer from bad food, who labour under 
the effects of indigestion, and who are exposed to the debilitating 
influences of impure air. 

In children of an opposite condition, also, the consequences 
of difficult teething often show themselves with great severity ; 
in these, whose condition is that of plethora, the effects of 
teething are often sudden and violent, and accompanied by 
much febrile disturbance and inflammatory action. In them, 
also, the cerebral disturbance is often very great, from the 
supply of blood required in the state of active developement of 
the brain. There can be no question that the greater number 
of diseases, at the time of teething, have their origin in plethora, 
induced by over feeding, or any other cause which will produce 
an irritated state of some of the organs ; thus predisposing the 
child to be influenced by the excitement of teething. Accumula- 
tion of heat, therefore, about the head, by having it too warmly 
covered, may excite a flow of blood to the cerebral organs. So, 



158 DISEASES OF CHILDREN. 

also, warm clothing generally will produce a febrile action, 
which, when the system is under the additional excitement of 
dentition, will be developed into some inflammatory or conges- 
tive disease. 

Semeiology. — There is always a considerable swelling, 
heat, redness and pain in the gums. Their tenderness is at 
first extreme, allowing scarcely any pressure. Afterwards, 
as the tooth advances towards the surface, a change occurs in 
the appearance and sensibility of the gum ; it is no longer so 
fiery red, and pressure rather gives ease than pain. The 
salivary glands enlarge, and an abundance of saliva flows from 
the mouth. With this afflux of blood to the mouth, stomatitis, 
in some of its various forms, arises. The blood being deter- 
mined to the head, a turgescence of the face and eyes will 
appear. Thirst, heat, restlessness, and the usual symptoms of 
fever, also show themselves : the sleep is disturbed, short, and 
unrefreshing, arising from the disturbance of the brain and 
nervous system. This irritation of the nervous system may 
increase, until some convulsive movement is observed, together 
with a rolling of the eyes during sleep. 

Other spasmodic movements may arise, and when affecting 
the glottis, produce a difficult and distressing respiration. This 
affection has been known by the names of spasmodic or chronic 
croup. M. Guersent has described it by the name of Pseudo- 
croup nerveux ; M. Gardien, by that of Spasme du thorax et de 
la glotte. It has also received the attention of Cheyne, Munroe, 
Hamilton, and others. This disease is more particularly de- 
scribed under the article of spasmodic croup, to which the 
reader is referred. 

The late Dr. Parrish has described a peculiar spasmodic 
affection of the intestines, arising, as he supposes, from the 
irritation caused by teething. The abdomen swells, while a 
spasmodic contraction of the muscles of the face and limbs 
takes place, and the ordinary action of the bowels is arrested 
from the same cause. On the escape of air from the bowels, 
<a complete relief to the symptoms occurs. 

During the period of teething, there is always a greater or 
less disturbance of the digestive organs, manifested by a mor- 
bid irritability of the stomach, and an acid odour of the breath 
and matters vomited. The diarrhoea, so common in teething 
children, is, when moderate, always to be regarded as a salu- 
tary evacuation, as it relieves the tendency in plethoric children 
to local congestions. This diarrhoea, however, should only be 
regarded as the effect of the simultaneous developement of the 
muciparous follicles of the intestines, which occurs with other 
parts of the system concerned in digestion : that is, the teeth 



DIGESTIVE SYSTEM. 159 

and salivary glands. The tongue, with this diarrhoea, continues 
natural, the appetite is unimpaired, and the child continues to 
thrive. Both the diarrhoea, and vomiting which sometimes 
occur, may continue until they become very serious and fatal 
affections. 

The vomiting and purging, so common in teething children, 
not unfrequently pass into a very serious disease. It has re- 
ceived particular notice from MM. Cruvielheir and Guersent ; the 
former of whom describes it under the name of Maladie gastro- 
intestinale des enfans avec desorganisation gelatiniforme. The 
name sufficiently indicates the nature of the disease, when it has 
passed from a simple disturbance of function, to a disorganiza- 
tion of tissue ; dissection showing that the mucous membrane 
of the stomach and intestines has been reduced to a pulp, but 
without any appearance of inflammation. 

Among the diseases to which children at this period are 
affected, one mentioned by Underwood as an occasional 
accompaniment of painful dentition, is a peculiar swelling of 
the hands and feet. He regarded it, like diarrhoea, as decidedly 
beneficial, or of but little importance.* It has, however, been 
described more at large by Dr. Kellie ; and although in some 
instances slight, yet at other times it has constituted a very 
serious affection. It arises suddenly, is of a purplish mottled 
appearance, without heat, or any sign of inflammation. The 
swelling first appears on the dorsum of the hand or foot, and 
is firm, and does not pit on pressure. It sometimes continues 
for a month, and usually disappears suddenly. At other times 
it assumes a leucophlegmatic appearance, and extends to the 
whole limb. This condition is generally connected with a spas- 
modic contraction of the fingers and toes. The thumb is 
strongly bent inward, and pressed into the palm of the hand, as 
the toes are bent in a similar manner on the sole of the foot. 
The carpus is at times drawn in such a manner as to increase 
the sphericity of the metacarpal bones. There appears to be but 
little pain in the affected part.f 

Diseases of the skin often occur during dentition, and from 
their disappearance on the protrusion of the teeth, are evident- 
ly caused by the irritation in the system at this period of life ; 
and like diarrhoea, appear to be salutary, and therefore, when 
connected with teething, ought not to be removed. Among 
these cutaneous affections are strophulus confertus, strophulus 
candidus, and the species of porrigo on the forehead and cheeks, 



* Treatise on the Diseases of Children, by Michael Underwood, M. D., p. 140. 
-r Notes on the Swelling of the Tops of the Hands, etc., by Geo. Kellie, M. D., 
Ed. Med. and Surg. Jour., vol. xii. p. 449. 



160 DISEASES OF CHILDREN, 

known by the names of crusta lactea, together with the 
erythematic effloresence and ulceration behind the ears. 

Dysuria, also, is an affection with which teething children are 
sometimes attacked. It occurs mostly in those that are debilita- 
ted, and whose digestion is feeble ; and acidity of the stomach 
is its invariable attendant. 

As all these disorders are considered in other parts of this 
work, it is unnecessary to treat of them here in detail. 

Morbid Anatomy. — In those children who have died from 
the effects of teething, manifested especially by great tume- 
faction of the gums, the post-mortem examination reveals a 
violet coloured swelling, with fluctuation. On opening the 
tumor, dark coloured fluid blood is found in the alveoli. The 
teeth are generally discovered loose and floating in- the midst 
of the effused blood, which formed the tumor, and fall out with 
the blood that flows. These effusions in the alveoli become 
less frequent in proportion as the child advances in age, and 
as the tooth by its size fills the alveolor cavity. Other patho- 
logical appearances occur in other organs, according to the 
nature and seat of the complication. 

Treatment. — There were formerly a number of strange 
and superstitious practices recommended for the treatment of 
difficult teething ; and the universal idea prevalent at every age, 
that something must be done, is an evidence of the distress that 
accompanies teething. The most barbarous, as well as the 
most refined, have thought it necessary to resort to some 
method of assisting the efforts of nature. The aborigines of 
our country gave smooth stones to their infants, with which to 
press their gums. The ancients, among those remedies that 
were rational, not unfrequently had recourse to such as had 
their origin in superstition or ignorance. Amulets and charms 
were formerly in common use ; and such remedies as the brains 
of a sucking pig, milk of a bitch, and the blood of a cock's 
comb, rubbed over the gums, were freely used, by being ap- 
plied to the part with the finger. The latter, especially, "is 
truly praiseworthy ; for this," says Harttman, " being only once 
or twice, at most, anointed on the gums with the finger, causes 
a production of the teeth without difficulty, and free from 
accident/'* However absurd these may appear, they still are 
evidences of the universal prevalence of morbid phenomena 
in teething children, and that the distress experienced by them 
requires the interference of art for its relief. 

The local treatment of teething, when there exist heat, swell- 
ing and redness of the mouth and gums, or, in other words, 

* Henlock's Practical Treatise on Teething, 1742. 



DIGESTIVE SYSTEM. 161 

when simple stomatitis is present, should consist of soothing 
emollients and mucilages. Cold water is exceedingly grate- 
ful to the hot and irritated mouth, and therefore the mouth 
should be frequently washed with it, and the child allowed 
freely to drink it; indeed, water ought frequently be given to 
a young child, especially in summer. A violent fit of crying 
will often be arrested by a draught of cold water. The in- 
stinct of the child for biting on hard substances, may be indulged 
with safety and advantage ; therefore, a smooth piece of coral, 
ivory, or gum elastic, may be given to the child for this purpose. 

The practice of furnishing children with a piece of coral is of 
great antiquity, and appears to have been connected with 
some superstition among the Romans, as we learn from the 
writings of Pliny ; it was a charm against witchcraft, and was 
a common amulet of the Roman children. The use of this 
doubtless had its origin in the benefit children derived from it, 
and the superstition connected with it, from the mystical attri- 
butes which were supposed to belong to the substance.* The 
use of hard substances has been objected to by some physicians, 
but without much reason; for it is evident that the absorption 
of the gum is greatly promoted by the use of these substances, 
and the child is obviously much relieved by the use of them. 
Dr. Good supposes ptyalism is promoted by the use of a ring 
of gold, as the experiments of Dr. Chrestien show that pow- 
dered gold, applied to the gums by friction, produced ptyaiism ; 
but it is probable that no particular advantage can arise from a 
gold ring over one of ivory or bone. A piece of liquorice root, 
or slippery elm bark, or a crust of bread, will a'so be found highly 
useful in promoting the flow of the salivary fluid. 

When the gum becomes expanded over the tooth, and there 
exists much local inflammation or general disturbance, it should 
be freely divided, until the tooth is felt. Such a free division 
of the gum will often prevent the occurrence of serious conse- 
quences, which sometimes attend on teething, and which a 
slight exposure to cold or error in diet may induce. The effect 
on the general system of a young infant, by the pressure of a 
growing tooth, may be understood better when it is considered 
that the membrane which covers the crown is put on the stretch, 
whereby the nerves at the root are crowded, and great pain 
and irritation caused by the pressure. In every disease, what- 
ever be its nature, the gums should be examined during den- 
tition, and if there are evidences of the advance of any of the 
teeth, the gum should be promptly divided ; for if the disease 

* Vide C. Plinii Secundi, Hist. Mundi, Lib. xxxii. Cap. ii. 
21 



162 DISEASES OF CHILDREN. 

be not caused by the teeth, for the reasons just mentioned, the 
most serious irritations will be produced by the confined tooth, 
and thus add to the existing disturbance of the system. 

The relief afforded to some children by the operation must 
be great, for they have sometimes, by pointing to the gum 
with the finger, signified a wish to have the operation repeated. 

Objections have been made to cutting the gum, and its pro- 
priety questioned ; but experience most abundantly proves the 
usefulness of the practice. It has been asserted, that the cica- 
trix which forms over the tooth, should the latter not appear 
immediately, will impede its advancement. This, however, is 
not true ; for it is now well ascertained, that newly cicatrized 
parts are the first to be removed by the absorbents, upon their 
excitement from any cause. Newly healed wounds, on the de- 
rangement of the system by which these vessels are brought 
into morbid action, soonest yield to their influence. The cica- 
trix would, therefore, rather favour the passage of the tooth, by 
its giving way easier to the process of absorption. It has been 
also said that the instrument might injure the teeth; but this 
cannot occur, for the enamel is fully formed, and will sufficiently 
protect the teeth against, any injury. The pain of the opera- 
tion, also, has been urged as an objection to its use. The pain, 
if any, is instantaneous, and not to be compared with the con- 
stant suffering of the child during the pressure of the teeth, and 
the relief always experienced on removing this pressure. It 
should be performed by laying the child horizontally on the 
nurse's lap, who must, also, firmly secure the hands of the child ^ 
the gum-lancet is then introduced by the operator, who, with 
one hand secures the immobility of the jaw, and an incision is 
made deeply through the tumefied gum to the tooth. It may 
sometimes be necessary to repeat the operation, in consequence 
of the return of pain, irritation and tumefaction; for the tooth, 
does not always appear, although the capsule in which it is 
enclosed be freely divided. 

As to the general treatment, it of course depends on the 
complications, which have nothing in them peculiar, except so 
far as they depend on the local irritation, or are aggravated 
by it. These diseases will be considered in their proper places, 
and our remarks be limited to the general management of 
children during the period of teething. 

As even the mildest cases are attended with great suscepti- 
bility of the system, every measure to keep the child calm and 
cool should be adopted. The head ought to be lightly covered, 
to prevent an undue accumulation of blood ; and it has even 
been advised, by experienced practitioners, to wash the head 
every day with cold water. But the propriety of a measure 



DIGESTIVE SYSTEM. 163 

like this may well be doubted, where the child has not been 
previously accustomed to such ablutions. It will be sufficient 
to use such measures as will naturally suggest themselves to 
every one, to prevent an increased determination to the brain, 
such as the avoiding the use of soft, warm pillows, the expo- 
sure of the head to the heat of a fire, or the rays of the sun. 

The tendency to indigestion in teething children will require 
the greatest care with respect to their food. If the child is at 
the breast, it should by no ' means be weaned, if there is a 
sufficient supply of food, until nature herself has pointed out, 
by the appearance of the first teeth, at least, that the child is 
in a condition to receive a different species of nourishment ; 
when an alteration may be made by commencing with some 
weak animal broth. When the child is artificially nourished, 
the lightest and least irritating food should be used ; milk and 
water, tapioca, sago, arrow root, or a mixture of rice water 
and milk. If the child appear to have a craving appetite, so 
as to require frequent feeding, by which a plethoric habit might 
be induced, it will be necessary to lessen the quantity of the 
nutritious portion, by diluting the food with water. One of the 
least irritating articles of food for a young infant, is the crumb 
of stale bread, well-boiled with water, and strained when it is 
first used, and mixed with a third of cow's milk; the consistence 
may be gradually increased or diminished, according to the 
necessity of the case. An error in diet, either in quantity or 
quality, may cause a great derangement in the prima? vise, and 
diarrhoea, accompanied with cholic and other distressing symp- 
toms, ensue. A moderate diarrhoea is both natural and salu- 
tary, and requires no interference. If, however, the discharges 
become green, attended with pain or much prostration, it will 
then be necessary to interfere for the relief of these untoward 
symptoms. The subject will be more fully considered when 
we are treating of diarrhoea, keeping in mind that a sudden 
stopping of the discharges from the bowels of teething infants, 
is always attended with danger of producing convulsions. 
The subjoined prescription will be found useful in controlling 
these evacuations, when they become excessive and prostra- 
ting.* 

Costiveness is best treated by enemata of warm water. Active 
purgatives should, if possible, be avoided, for there is a strong 



* fy Pulv. Ipecac, gr. j. 
Hydr. Subm., gr. ij. 
Cretse, p. p., gr. xx. M. 
Divid. in pulv. No. iv. 
One may be given every three or four hours, until the discharge becomes lessened. 



164 DISEASES OF CHILDREN. 

tendency in the inflammation which exists in the mouth, to 
extend to other portions of the mucous membrane lining the 
digestive passages. A small piece of manna, dissolved in the 
milk and water with which the child is fed, affords a good 
laxative for this condition of the bowels. 

The child should be regularly accustomed to use such kind 
of exercise as it is capable, and if not rendered hazardous by 
existing diseases, taken in the open air when the weather is 
good ; for there is scarcely any thing that tends sooner to 
excite febrile irritation, and a disordered condition of the bowels, 
than close confinement within doors, particularly in cities, 
during the summer. 

Cutaneous affections in teething children demand an especial 
attention. But it ought here to be remarked, that great care 
should be observed in the application of remedies for their re- 
moval, as fatal consequences have not unfrequently ensued 
from the drying up of eruptions behind the ears and on the 
head ; they had much better be left without any other applica- 
tions than such as are necessary to preserve cleanliness. 

TONSILLITIS— INFLAMMATION OF THE TONSILS. 

Among the parts of the digestive system which are very lia- 
ble to inflammation in children, particularly after the fourth or 
fifth year, are those masses of mucous follicles known by the 
names of tonsils or amygdalae. As their office appears to be to 
lubricate the upper part of the pharynx, and one of the most 
common inconveniences arising from their inflammation being 
pain in deglutition, it appears proper to class them at least as 
appendages to the digestive organs. 

This d.sease has been known by the various names of amyg- 
dalitis, cynanche tonsillaris, angina, squinancy or squinsy, of the 
old medical writers. Hippocrates speaks of it ; and it is also 
clearly described by Celsus, Aetius and others, among the 
Romans. 

Etiology. — The most common cause is cold applied to the 
surface of the body ; and it is consequently found most prevalent 
in damp situations, and in cold, variable climates, and at the sea- 
son of the year when most atmospherical vicissitudes prevail, 
as the autumn and spring, especially the latter. Those children 
who are of a sanguineous habit of body are greatly liable to 
attacks of this disease ; and a great predisposition to renewed 
attacks exists in those who have once been affected. 

Semeiology. — This d.sease is easily recognised by the redness 
and tumefaction of the fauces. Where the inflammation is se- 
vere, the tonsils become exceedingly swelled, so as to impede 
deglutition ; the uvula and soft palate appear also swelled and 



DIGESTIVE SYSTEM. 



165 



(Edematous. When attempts are made to swallow, great pain 
is produced by the effort; and in severe cases of this disease, 
fluids are sometimes returned by the nose. The tongue is 
white, the papilla? being seen in red dots through it at the com- 
mencement ; afterwards a thick tenacious mucus covers the 
whole surface of this organ. As the disease advances, the clog- 
ging of the fauces by the thickened secretion, together with 
the enlargement of the affected part, cause a difficulty in res- 
piration, and a total inability to swallow. 

For the most part there is a great deal of fever accompanying 
this affection, and usually ushered in by a universal chilliness ; 
the pulse is full and strong ; the carotids beat with great force, 
and the face is flushed and swollen. The eyes, in violent cases, 
are red and prominent; and when the fever is great, the general 
turgescence of the brain causes a compression of the cerebral 
mass, and delirium ensues. The external parts of the throat 
and neck are greatly swelled, and give the strongest evidences 
of sanguineous congestion. 

After the inflammation has continued for a short time, resolu- 
tion, one of its most frequent terminations, takes place, and the 
patient recovers his strength in a few days ; occasionally, how- 
ever, great debility follows, and convalescence is protracted. 
It also frequently terminates in suppuration of one or both ton- 
sils, which will occur even after the most prompt and decided 
treatment. The discharge of the pus thus accumulated, either 
spontaneously or by artificial means, affords immediate relief to 
all the urgent symptoms. 

In some instances the inflammation is stationary, neither a 
disappearance of the tumors nor suppuration occurs, but a per- 
manent enlargement of the tonsils remains. This, it is said, is 
most likely to occur in children of a scrofulous habit, and those 
who are predisposed to phthisis. 

Pathology. — Redness, tumefaction, suppuration and ulcera- 
tion, are the anatomical characters of tonsillitis ; such as have 
been described under the semeiology of the disease. 

Treatment. — The antiphlogistic treatment is that which is 
especially demanded in this affection. In mild cases, saline pur- 
gatives,* warm pediluvium, rubefacient liniment to the throat, 
and diluents, will be all that will be required. Indeed, purga- 



* # Infus. Ros. Co., gvss. 

Magnes. Sulph., 3vi. 

Syrup. Lemon., §ss. M. 
One or two teaspoonsful every three 
hours. 



ty Magnes. Sulph., oij. 
Mannae., §j. 
Solve in 

Emuls. Armygd., §iv. M. 
A dessert-spoonful every two hours, 
for a ehild two years old. 



166 DISEASES OF CHILDREN. 

tives are highly useful in tonsillitis ; and where it is necessary 
to administer such as will make a more decided impression on 
the system than those just mentioned, a few grains of calomel, 
followed by either of these saline cathartics. A mixture of Ep- 
som salts and tartar emetic, so as to operate both by the bowels, 
and restore the healthy action to the part by its emetic effect, 
would in most cases be advisable. The restoration of the cu- 
taneous secretion is also indicated ; and one of the best articles 
for lessening febrile action in children is nitrate of potass,* and 
when combined with ipecacuanha, forms an admirable diapho- 
retic in mild cases. f Tartar emetic, one grain in two or three 
ounces of water, a teaspoonful every two hours, may also be 
given for the same purpose. In young children, especially 
where there is much viscid secretion around the fauces, an 
emetic is highly useful, and in some cases decidedly necessary, 
to relieve the entrance to the respiratory passages. 

In severe cases of this disease, with great febrile action and 
full pulse, it will be necessary to bleed from the arm. In all 
cases, when the disease does not yield to the remedies first 
mentioned, it will be proper to apply leeches to the swelling, 
or to scarify the inflamed tonsils. When leeches are applied, 
a warm poultice ought to be put around the throat ; indeed, an 
emollient poultice is one of the best applications in ordinary 
xBases, under all circumstances. Blisters should be used on the 
back of the neck or throat, after the action of the blood vessel 
is in some measure subdued, and the disease continues without 
abatement. 

Acidulated astringent gargles have been recommended by 
various practitioners, but in the ordinary inflammation there 
can be hardly any advantage from them ; and Pringle says that 
he never saw any good resulting from their use. Eberle, also, 
disapproves of their use, and recommends in their place sim- 
ple warm water, acidulated with vinegar, for the purpose of 
removing the viscid mucus about the tonsils and palate. These 
astringent gargles, however, may be used with advantage, after 
the tonsils have suppurated, and have been opened, or have 
discharged spontaneously. J 



* fy Mucilag., gij. 
Potass. Nit.', 3j. 
Oxymellis, giss. M. 
Sit linctus. A teaspoonful to be 
slowly dissolved. 

t ^ Pulv. Ipecac, gr. iij. 

" Potassse Nit., gr. xii. M. 
Ft. Pulv. No. vi. 
Dose, one every three hours. 



t ~fy Gtuerci, 3ij. 
Aluminis, 3ss. 
Aquae Fervent, oj. 
F. Gargarisma. 
fy Tinct. Myrrhae, 3ij. 
Acid. Sulph. Dilut., 3j. 
Aluminis, gr. x. 
Decoc. Hordei, oj. 
Ft. Garg. 



DIGESTIVE SYSTEM. 167 

When suppuration is about to take place, every means in 
our power should be used to effect it. Poultices should be con- 
tinued externally, and the vapour of warm water frequently 
inhaled. As soon as the matter appears to be formed, the 
tumour must be opened with a lancet, rather than let the patient 
run the hazard of his life, by allowing the tumefaction to con- 
tinue, for the suffering from the excessive swelling is sometimes 
very great, and the danger of perishing from suffocation immi- 
nent. In a few instances, the abscess has pointed and broken 
externally. In some cases, the tumefaction has been so great 
as to render it necessary to make an opening into the trachea ; 
an operation which has been performed at different parts of that 
tube. 

CYNANCHE MALIGNA.— MALIGNANT SORE THROAT. 

This disease has, at times, made frightful ravages among 
children in different parts of Europe ; and from the number of 
records of its history which we have received, there is no 
want of information relative to its symptoms, progress, and the 
supposed nature of the morbid changes occurring in this variety 
of inflammation of the tonsils and fauces. From the earliest 
ages in which there exists any account of medical writings, it 
appears to have *been described in some form or other. Are- 
taeus speaks of it; and the ulceration of the tonsils is clearly 
recorded by him, corresponding remarkably with the modern 
account of the affection.* Since the commencement of the 
seventeenth century, its prevalence in the southern countries of 
Europe, and islands of the Mediterranean, has enabled nume- 
rous authors to describe the symptoms, course and ravages of 
the epidemic. During the following century, its extensive pre- 
valence throughout Europe has caused a number of accounts to 
be published, and many excellent essays now exist on this sub- 
ject. Although not so severe, it has appeared as an epidemic 
in this country, and the first mention' of it is in the early part 
of the last century. 

The peculiar product of the inflammation, the pseudo-mem- 
branous formation which is poured out on the surface of the 
inflamed mucous membrane, has of late received much attention 
in France ; and the description of it, principally by Bretonneau, 
has probably been taken from the milder form of the affection ; 
for the term he applies to it, diphtheritis, (ac^o, membrana,) 
signifies an inflammation, attended with an exudation of a mem- 
branous substance, which is represented as its only peculiarity, 

* Aretaeus, de Caus. et. Sig. Acut. Movb., Lib. ii. 



168 DISEASES OF CHILDREN. 

but which, in strictness, cannot always be so regarded. In 
some instances the pellicle may be peeled off, leaving the mu- 
cous membrane beneath red, and free from any ulceration ; but 
in the greatest number of instances, it is found covered with an 
ash-coloured slough, or studded with patches of gangrene,* 
corresponding with the malignant sore throat of earlier wri- 
ters. This affection, known also by the names of angine 
coenneuse,f angina pseudo-membranacea, etc., ought to be con- 
sidered identical with cynanche maligna.J 

Etiology. — Cynanche maligna, or ulcerated sore throat, is 
most prevalent in spring and autumn ; and it has been thought 
that a damp atmosphere, or a low marshy situation, is neces- 
sary to its production ; but such has not always been found to 
be the case; for in an epidemic in France it prevailed during a 
remarkably dry season, and the marshy districts were even 
more free from the disease than more elevated situations. It 
usually prevails as an epidemic. Sporadic cases of it also 
occur, but are in general of much less violence than when 
raging among a community in a town or village. It is said 
that it appears simultaneously among several individuals ex- 
posed to the same influence, while other members, similarly 
exposed, have escaped entirely, and other persons having 
intercourse with them have not been affected, whence it has 
been inferred that it is not contagious. 

On the other hand, those who have been careful observers 
of the disease, and who have had abundant opportunities of 
remarking its nature and progress, strongly maintain its con- 
tagious character. M. Trousseau asserts, that one individual 
affected with it may introduce it into a community, and cause 
its spread through several individuals in every variety of its 
forms. Several instances of its contagious character are given 
by this writer,|| as well as by Guersent,§ Bretonneau, and 
others. Like most diseases of like nature, it may become 
communicable under peculiar circumstances, as in a state of 
atmosphere resulting from crowded habitations, want of cleanli- 
ness, insufficient, ventilation, and other causes which may render 
it vitiated. These circumstances may reconcile the conflicting^ 
opinions on this subject. Those most liable to an attack of 
this affection are children ; and when they are crowded together 



* Evanson and Maunsell, p. 130. 

t Guersent, Diet, de Mdd. 

t V. An excellent Monograph, by Professor Geddings, of Charleston, Sotfth 
Carolina, on Pseudo-Membranous Inflammation of the Throat. Amer. Journ. 
Med. Scien., May, 1839. 

II Diet, de Med., art. Diphtherite. 

§ Ibid. Art. Angine Membr. 



DIGESTIVE SYSTEM. 169 

in close habitations, and especially when suffering from poverty 
and filth, are very violently and fatally affected. Yet it not 
unfrequently happens that numbers are attacked with it who 
enjoy every comfort and luxury of life. 

Semeiology. — This disease is very insidious in its approach. 
A little chilliness, languor, stiffness of the throat, are all the 
symptoms which precede an attack. In some instances, indeed, 
the child manifests no distress nor uneasiness, and when old 
enough to describe his feelings, expresses no inconvenience, 
except a slight burning in the throat. If the fauces be examined, 
even at the earliest period of the disease, they will be found of 
a deep red, covered either partially or generally with transpa- 
rent mucus. This mucus gradually increases in quantity and 
consistency until it has the appearance of a concrete covering 
or plastering, of a grayish colour, inclining to yellow. This 
may often be peeled off, leaving minute bloody points on the 
mucous membrane, which, in the milder form of the disease, 
is not much swollen. The pellicle at first, in detached portions, 
soon becomes confluent, and the whole of the fauces and mouth 
become lined with this thick exudation. 

The colour of this pseudo-membrane is at first grayish, it 
then becomes brown, and afterwards black. The mucous 
membrane beneath, when it is exposed to inspection, is now 
found to be of a dark red, soft, and is easily made to bleed. At 
this stage of the affection, the cellular membrane participates 
in the disease, or in the irritation arising from it, and the neck 
and adjacent parts become swelled. Sometimes the inflamma- 
tion, and its effects, spread to the larynx, giving rise to the 
secondary form of croup. 

As the disease advances, or in those cases which, from the 
commencement, are more than usually severe, the tonsils and 
fauces become more swelled, and the exudation assumes a dark 
ash, or brown colour, which being thrown off in shreds, leaves 
the parts beneath in a sloughing condition. The sloughs ra- 
pidly extend into the substance of the tonsils and surrounding 
parts, while a dark coloured sanies is discharged from the nose ; 
and vesicles, which become gangrenous, appear on the inner 
surface of the cheeks and tongue. The mouth is dry, dark- 
coloured, and finally black ; the gums become soft, and partake 
of the general disposition to slough. The tongue at first is 
red at its edges, and white on the surface ; afterwards it be- 
comes brown or black, and dry, while small ulcerations appear 
on its sides. Nausea and tenderness in the epigastrium indi- 
cate the existence of gastritis in severe cases, and diarrhoea 
not unfrequently occurs under such circumstances. 

At the commencement of the disease, the febrile symptoms 

22 



170 DISEASES OF CHILDREN. 

are often considerable, but they abate in intensity as the disease 
advances. The pulse becomes irregular and frequent, and a 
general prostration of the powers of life ensues, and the patient 
perishes from hemorrhage, induced by the extensive separa- 
tion of the eschars, or from the exhaustion, caused by the diar- 
rhoea, which so often attends a violent attack of the disease. 

It has been confounded by many writers with scarlatina, 
Fothergill, Cullen, Withering, Morton, Bard, and others, regard 
the eruption of scarlatina as a pathognomonic symptom of the 
disease, considering the two as identical. The scarlet eruption, 
however, is not necessary to the characters of malignant sore 
throat, as the latter often occurs without the other, and is truly 
an idiopathic affection : an inflammation which derives a pecu- 
liar character from some local or epidemic cause. I have 
very recently seen a rapidly fatal case of sporadic malignant sore 
throat, without any of the usual marks which characterize 
scarlatina, and without being able to discover any case of the 
latter disease in the vicinity. 

The prognosis is generally unfavourable, when there appears 
much tendency to sloughing, accompanied with great prostra- 
tion of strength, or any local congestion of an important organ. 
If the disease has continued mild for the first week, a favourable 
termination may be expected. If there should arise any laryn- 
geal or gastric inflammation, the complication gives an unfa- 
vourable prognosis. 

Pathology. — Bretonneau regards the membrane, formed in 
the disease he denominates diphtheritis, as the result of specific 
inflammation ; but in what it consists, he finds it difficult to 
say. There is doubtless an influence produced, by the opera- 
tion of the epidemic causes affecting the nervous energy, by 
which a peculiar character is imparted to the inflammation. 
Naumann was of opinion that a change was wrought in the 
properties of the blood, by which its albumen could not be 
retained in solution, and it exuded on the inflamed surface.* 
It is a curious coincidence, also, that in this disease, according 
to the experiments of Donne, the secretions are highly acid ; 
and Raspail's views are, that fibrine is only coagulated albumen 
from the effect of acid. The loss of the power of interstitial 
growth, and the derangement of the secretory function of the 
diseased part, and the changes wrought in the secreted matters, 
which give evidence of the great tendency to gangrene, show 
the effect of the epidemic influence on the ganglionic nerves, 
by which their energy is impaired, and their controlling power 
over the secretion of a diseased part in a measure lost. 

* Handbuck der Med. Klinik, bande iv. p. 81. 



DIGESTIVE SYSTEM. 



171 



Treatment. — A great difference of opinion has existed as 
to the treatment of this disease, attributable to the different 
appearances the disease has assumed in the various epidemics ; 
accordingly, where the epidemic has been marked with the 
predominance of inflammatory action at the commencement, 
bleeding has been resorted to from necessity, and the remedy 
considered as one of the greatest importance in the manage- 
ment of the disease. In individuals, too, of robust frame, in whom 
the invasion was attended with a vigorous action of the san- 
guineous system, and the usual attendants, heat and tenseness of 
the pulse, such cases of abstraction of blood would be the remedy 
most naturally suggested. Even, therefore, in the same epi- 
demic, a difference of treatment might have been found neces- 
sary ; and the opposite views of Gendron,* recommending 
bleeding, and those of Bretonneau, disapproving of it, may 
thus be reconciled. 

In the early stage of the disease, especially in vigorous chil- 
dren of sanguineous temperament, bleeding should be prac- 
tised with the lancet, together with leeches to the throat ; in 
attacks characterized with less disturbance of the general sys- 
tem, and less violence of the local inflammation, blood-letting 
may be limited to the application of leeches to the throat. 
Where there exists, however, much depression of vitality, with 
a cool skin and feeble pulse, even at the commencement, blood- 
letting, in every form, should be avoided, for even the leech bites 
will slough under circumstances like these. 

One of the most important remedies, where there is no gas- 
troenteritis, is an emetic, not only for the purpose of removing 
the membranous formation and sloughs from the throat, but 
also from its general revulsive effect. Sulphate of zinc is one 
of the best that can be used. It may either be given alone, in 
doses of two or three grains in two ounces of water, by spoons- 
ful, every ten minutes, or in combination with ipecacuanha, f 

Mild aperients will be all that will be required throughout the 
whole of the disease, where the condition of the bowels de- 
mands the interference of art to keep them in a soluble condi- 
tion. All other kinds of cathartic medicines should be avoided, 
on account of the great tendency to diarrhoea. J 



* Note sur l'Angine couen., etc.. 
Journ. Complimen. des Soc. Med., t. 
xxx., p. 269; Paris, 1828. 
t fy Sulphat. Zinci., gr. v. 

Pulv. Ipecac, gr. xxv. M. 
Divid. in pulv. No. v. 
One every fifteen minutes. 



t Jjc 01. Olivee, 3ss. 

Pulv. Acacise, q. s. ut fiat, 

cum Aq. Fceniculi, giij. 

emulsio, cui adde, 

Mannse, §j. 

Syrupi, §ss. M. 
A dessert spoonful every hour. 



172 DISEASES OF CHILDREN. 

Calomel, as a cathartic, has been strongly recommended by 
Dr. Jacob Ogden, formerly of Jamaica, L. L,* Dr. Bayley,f 
and others. Bretonneau has also used it with advantage ; he 
says it not only cleansed the throat, but produced a general 
subsistence of all the unfavourable symptoms. On the other 
hand, respectable and experienced practitionersj have not 
found any advantage in the use of it. It is not only admissible 
in the earliest stage of the disease, and in plethoric and vigor- 
ous individuals, and where the disease has at the commence- 
ment extended to the larynx, producing symptoms which indi- 
cate the existence of croup, but throughout the entire disease. 

External stimulating applications are undoubtedly useful 
to produce a revulsion to the surface. Any of the ordinary 
rubefacient liniments may be used for this purpose ;|| but blisters 
should, under ordinary circumstances of gangrenous sore throat, 
never be used to the part, from the great tendency of all sores 
to slough ; they are only admissible when there is much swell- 
ing of the throat, and after the violence of the inflammatory 
action has in a measure been subdued. Those who have had 
experience in the epidemics that have prevailed in Europe, 
recommend them, under the circumstances just mentioned, to 
be applied to the nape of the neck. 

A tepid bath, at the commencement of the disease, will 
greatly tend to restore the equilibrium to the circulation ; and 
the constant sponging of the body with tepid vinegar and water, 
while a febrile heat continues, will be found both refreshing to 
the patient, and tend much to the diversion of the disease, by 
constantly exciting the action of the cutaneous follicles. Warm 
sinapised pediluvia may also be repeatedly used with advan- 
tage. To allay the febrile action, the effervescing mixture 
of supercarbonate of soda, or potass, may be employed ;§ 
the latter is peculiarly soothing to an irritated stomach, and 
may with safety be used, when there exists much gastric irri- 
tation. Where there is gastric inflammation, cold, iced drinks 
are much craved by the patient, and will be found highly 
serviceable. 

This method of treatment is, of course, applicable only to 



* V. Dr. Ogden's Letters to Mr. Hugh Gaine, " On the Malignant Sore 
Throat Distemper," dated 1769-1774. Republished in Med. Repos., vol. v. 
t New-York Med. Repos. 2 Hex. vol. i. p. 331.— 3 Hex. vol. ii. p. 345. 
t V. Roche, art. Angine couenneuse, Diet, de Me'd. 



II fy Aquae Ammoniac, 
01. Olivar., aa. §j. 
Tinct. Camphorse, gss. 
01. Terebinth., 5ij. M. 
ft. Linim. 



§ fy Potassse Bicarb., 3j. 

Aquas, gij. M. 
A dessert spoonful every two hours, 
mixed with Succ. Limon., 3j. 



DIGESTIVE SYSTEM. 173 

those cases which possess more or less of an inflammatory ac- 
tion. When, however, the skin becomes cool, the pulse feeble, 
the inflammation of the fauces disappearing, and the part as- 
sumes a dark, gangrenous appearance, it will be necessary to 
resort to such measures as will restore energy to the system ;* 
as ammonia, camphor, wine whey, snake root in infusion,f 
mineral acids,J etc. This course of treatment must only be 
adopted when there is a decided sinking of the system, and the 
disease has assumed the gangrenous form. And when it is 
necessary to adopt a more tonic course, sulphate of quinine, 
enemata of infusion of bark and camphor,|| may be required ; 
the latter especially, where there still exists much gastric irri- 
tation. When it is thought advisable to give it by the mouth. 
in severe forms of the disease, with great loss of vitality, it 
may be administered according to the annexed formula. As 
a powerful and efficient stimulant, a mixture of capsicum and 
salt has been used with great benefit.§ 

To cleanse the throat, and stimulate the ulcerated surface to 
a new action, stimulating and detergent gargles have been 
long in use.1I When, however, sloughing has actually taken 
place, cauterizing the affected part becomes indispensable ; and 
the best method of effecting this is by means of a pencil of lu- 
nar caustic, or the powder applied to the part with a pledget 
of lint, covered with some glutinous substance, to which the 
nitrate of silver will adhere ; or a pledget on the extremity 
of a probe may be saturated with a solution, composed of twenty 
grains of nitrate of silver to an ounce of water, with which the 
part should be touched two or three times a day. Muriatic 
acid has also been used for the same purpose.** 

Nitrate of silver is decidedly the best for general use, as but 



* fy Ammoniae Carb., gr. viij. 

Mist. Acacise, 

Syrup. Simpl., aa. 3ss. 

Aquae, 3iv, M. 
A teaspoonful every two hours, 
t fy Rad. Serpent., 3iss. — 3iij. 

Inf. in s. q. Aq. per £ hr. 

Colatur., §iv. refrig. 

Adde, 

Syrup. Aurant., %']. M. 

A tablespoon ful every hour. 

t # Acid. Sulph. dil., 3ss.— 3j. 

Aquae, iv. 

Syrupi, 3j. M. 
A tablespoonful three or four times a 



II R- Cort. Cinch., 3ij. 
Aquae, §iij. 

Aq. Camphor., 3ss. M. 
ft. Enema. 

§ IJ: Capsici, 3iij. 
Soda Mur., 3ij. 
Aquae Fervent., §vii]\ 
deinde Adde, 
Aceti, gviij. M. 
A teaspoonful every hour. 



IT $ Herbiae Salviae, gss. 
Inf. Aquae Fervid, q. s„ 
Colatur, §viij. 
Acid. Hydrochlorici, 3iss, 
Syrup, gij. M. 

** Guimier. M6m. sur un Epidem. d'Angine Malig., &c, Journ. Ge*n. de 
MeU ; Paris, 1828.— Guersent, art. Ang. Gang., Diet, de MeU 



174 DISEASES OF CHILDREN. 

little irritation is left after the formation of the eschar by its 
use. Alum, chloride of soda, sulphate of copper, sulphate of 
zinc,* have each in their turn been found of great efficacy as 
escharotics or stimulants, according to the strength in which 
they are employed. Guersent and Bretonneau speak very 
highly of alum ; and Guersent has used chloride of soda, or the 
borate of soda, with decided advantage. Dr. Geddings sug- 
gests the use of creosote, properly diluted, as an escharotic. 
He also mentions that tincture of cantharides, either pure or 
diluted with one half or two thirds of water, has been used by 
him, injected into the throat by means of a syringe, when the 
patient is unable to swallow. 

PAROTITIS.— MUMPS. 

As an appendage to the digestive system, the inflammation 
affecting the parotid gland in children next comes under con- 
sideration. The mumps is a disease which few children 
escape, and having once been affected with it, rarely if ever 
have a second attack. It is for the most part a trifling affection, 
scarcely ever demanding much interference. 

Etiology. — Inflammation of the parotid gland may be pro- 
duced by the causes which usually develope inflammatory 
affections ; such as exposure to cold, wet feet, or damp bed 
clothes, in those who are predisposed by a sanguineous tem- 
perament to inflammatory diseases. Besides arising sporadi- 
cally, it may also prevail as an epidemic, when it is manifestly 
contagious, spreading through a family when once introduced, 
few if any of those who have not before been affected escaping 
its influence. 

Semeiology. — The disease first appears as a swelling, either on 
one or both sides, in the vicinity of the ear. When it first shows 
itself it is evidently confined to the parotid gland, as it is move- 
able. The cellular tissue is then involved, and a large swelling 
occupies the region around the angle of the jaw and cheek. When 
severe, it extends sometimes to the maxillary glands, causing a 
good deal of uneasiness, but scarcely ever producing severe pain. 
Is usually passes through its stage of increase in four days ; after 
that period it gradully declines. 

In the greatest number of instances it is a very mild disease, 
attended with but few marks of inflammation of the part, other 

+ # Zinci. Sulph., 3j. 
Infus. Salvise., 3ij. 
Mellis Rosae, §j. M. 
ft. Linctus. 



DIGESTIVE SYSTEM. 175 

than tumefaction, with no attendant fever. At other times, 
especially when the neighbouring glands are involved, its symp- 
toms are more violent, inflammation is more severe, the fever 
is high, with a great determination to the brain, as appears from 
delirium and other cerebral affections, which, it is said by Dr. 
Cullen, have proved fatal. This latter symptom, it has been 
remarked, is more likely to occur, where the disease passes 
through its course without exhibiting the peculiar sympathetic 
affection of a transfer of inflammation to the testes, or mammae ; 
a symptom very commonly occurring when it is first on its 
wane. 

Although, in the greatest number of instances, the local in- 
flammation is but light, yet it has at times been so severe as to 
terminate in suppuration of the parotid, tonsils, and neighbour- 
ing parts, or even in scirrhus ; the latter, however, is rare in 
young subjects, as is also the occasional termination in chronic 
and malignant diseases of the part, which have been observed 
in old persons. 

Treatment. — It is in most cases so slight as scarcely to re- 
quire any other treatment than a gentle cathartic, pediluvium, 
and the application of some stimulating liniment to the skin of 
the affected part. This, with abstinence, will usually abate the 
inflammation, and facilitate the natural tendency of the disease 
to resolution. 

When the local inflammation is severe, and the accompanying 
fever violent, with a determination to the brain, venesection 
must be resorted to, with active cathartics and diaphoretics ; 
and when the violence of the constitutional symptoms have been 
in some degree subdued, a blister should be applied behind the 
ear. The local abstraction of blood, by means of leeches, should 
never be omitted when the symptoms of inflammation are vio- 
lent ; and even when there exists no febrile action, they ought 
to be used, if the violence of the local inflammation threatens 
the formation of an abcess. After these, a fomentation of hops 
will be found useful in allaying the local nervous excitement, 
which often greatly influences inflammatory action. Where 
the termination of the inflammation is evidently tending to an 
abscess, notwithstanding the measures adopted for subduing it, 
the secretion of pus must be promoted, by the application of 
soft poultices of bread and milk, or slippery elm. 

On the disappearance of the disease, the bowels should be 
kept free, to prevent the translation of the disease to other 
organs ; this, however, need not be feared, where proper mea- 
sures are employed in the course of the affection. 



176 DISEASES OF CHILDREN. 



CESOPHAGITIS.-INFLAMMATION OF THE OESOPHAGUS. 

Oesophagitis is a disease of much greater frequency in young 
infants than is generally supposed. It occurs more frequently 
in them than in adults, and is probably often the cause of 
vomiting. Indeed, it is in the latter of rare occurrence, and is 
caused by the introduction of some irritating or corroding poison ; 
but in the infant it is a disease peculiar to the period of life, 
arising from the natural congenital predisposition of the part to 
inflammatory action. It is an affection often overlooked or con- 
founded with some other disease. 

Etiology. — The congenital congestion of the oesophageal 
canal in new-born infants, as appears from modern dissections, 
is one of the predisposing causes of this affection, and is on this 
account, as was before observed, of much greater frequency 
than in adults. The exciting causes are principally the high 
temperature of drinks or food which the child takes. It not 
unfrequently arises from heated milk, panada, or other food, 
which is given to an infant artificially nourished ; and it is easily 
conceived how this organ, predisposed by sanguineous conges- 
tion, may become by these means seriously inflamed. 

Semeiology. — One of the most prominent symptoms of oeso- 
phagitis in infants, is the vomiting of the milk immediately on 
swallowing. From the pain arising on swallowing the child 
refuses the breast, and becomes rapidly emaciated for want of 
nourishment. Not unfrequently other matters which come 
from the stomach are vomited, besides the milk which the child 
takes ; when this is the case, there is probably an extension of 
the inflammation towards the stomach. The cause of the in- 
cessant vomiting in oesophagitis is doubtless owing to the con- 
tractions arising from the stimulation of the part by food. 

It is not an easy matter to distinguish this affection from 
diseases of the stomach, for the symptoms are few in number, and 
are generally similar to those which characterize inflammations 
of the gastric organ, such as refusal of the breast, vomiting 
after deglutition, and emaciation. Yet it may be suspected, if 
the vomiting occur immediately after an attempt at deglutition, 
and that the substances vomited exhibit no alteration ; the milk 
given shows no change in its character, such as is usual to find 
after it has been submitted to the action of the gastric secretion. 
Another method of detecting the existence of this disease, is the 
pain produced upon pressing along the track of the oesophagus, 
by which the cries of the child may be excited ; this is indeed 
the only way we have of ascertaining the existence of pain, 
for children at the age at which they are usually the subjects 
of this affection, are unable to indicate its presence in any other 
way. 



DIGESTIVE SYSTEM. 177 

In the case of stomatitis extending towards the fauces, we 
may have every reason for believing that the progress of the 
inflammation on the continuous membrane may not be arrested 
before it reach the oesophagus ; and in the different varieties of 
this affection, the oesophagus may also become affected, and its 
existence should be suspected when vomiting supervenes on 
the other symptoms. 

Morbid Anatomy. — The anatomical characters of this dis- 
ease do not differ materially from those of stomatitis. The 
habitual congestion of the oesophagus in new-born children, 
might sometimes lead to an error in supposing this canal to be 
inflamed, when it is really not in that pathological condition. 
When oesophagitis exists, there is almost always present some 
lesion by which the disease will be sufficiently identified, such 
as a destruction of the epithelium, ulcerations, and a peculiar 
carmine hue of the whole tract. The surface of the mucous 
membrane is sometimes found covered with the concrete exu- 
dation found in stomatitis. The pharynx is usually much in- 
jected ; the glottis infiltrated and red. Besides the separation of 
the epithelium, often in large shreds, several red, and sometimes 
black striae exist, where the epithelium is not destroyed. Ex- 
tensive ulcerations, also, have been found after a violent case 
of oesophagitis, characterized during life by the extreme obsti- 
nacy of the vomiting. Large irregular eschars, of a soot black 
colour, with intervals of deep bright red excoriations, the 
eschars diffusing the peculiar odour of gangrenous parts, have 
also been revealed on dissection. Some portions of the oeso- 
phagus have been found in a state of gelatinous softness, and 
apparently at the point of being perforated. 

Treatment. — Abstinence from the exciting causes is the first 
step in the treatment of oesophagitis ; this is more especially to 
be mentioned, from the great danger of disregarding the tem- 
perature of. the drinks which must at all times be given to the 
infant for nourishment. Hot and stimulating drinks should 
therefore be carefully avoided, and but small quantities given 
at a time, and at the temperature of breast milk. A mild 
aperient should be given, and its operation promoted by ene- 
mata. An emollient cataplasm ought to be applied to the throat, 
and in violent cases, a leech or two in the vicinity of the affected 
part, followed by a poultice. Mucilages ought then to be freely 
given, and, if possible, in such a manner as to keep the surface 
of the oesophagus continually coated. The slippery elm, as 
advised in the preceding section on stomatitis, will be one of 
the most useful forms in which they can be administered. 

23 



178 DISEASES OF CHILDREN. 



DISEASES OF THE STOMACH AND INTESTINES. 

It is a well established axiom in physiology, that in proportion 
to the vigour with which an organ discharges its peculiar 
functions, is it liable to be deranged in its healthy action ; the 
more it is exercised, the more is it disposed to disease. The 
organs most in active exercise in children, are those concerned 
indigestion, and their derangements are the affections for which 
the physician is most frequently called to prescribe : indeed, so 
common are they, that almost all the diseases of infancy have 
been referred to a disordered or ascessant condition of the 
digestive organs, as their original cause, by many authors. 
Van Helmont, Baglivi, Cheyne, Baumes, Gardien, Sablairoles, 
Senn, Denis, and others, have regarded the digestive system 
of infants as the foundation of their various affections. The 
celebrated and learned English physician Harris, considered 
the ascessant state of the stomach as the cause of every disease 
in infants.* 

The stomach and bowels may be disordered in their functions, 
simply from an altered action in the organs themselves, or 
from some disease tending to a change or destruction of their 
tissue, or they may be affected by sympathy with a distant 
part, as the head, lungs, skin, etc. From whatever cause these 
affections may arise, they cannot long continue, without becom- 
ing hazardous to the life of the young being, in whom the 
digestive and nutritive process are the principal functions, and 
the interruption of which at once arrests its growth, and de- 
ranges the harmony of action dependent on the general and 
simultaneous developement of all its parts. 

The idiopathic functional disorders and organic affections 
of the digestive system, will now be considered ; and such as 
arise from mere sympathy with other parts, will be left to be 
discussed when the diseases of which they are but the symp- 
toms are considered. 

INDIGESTION. 

Etiology. — In sucking infants, indigestion usually arises 
from the acrid and irritating quality of the nurse's milk ; it also 
arises from an inadequate supply, or a deficiency or excess of 
the nutritious qualities of the milk. In the former case the 
quantity is often not diminished, but its nature is changed, and 
it becomes a constant source of irritation to the tender mucous 
membrane, instead of affording a bland nourishment. 

* De Morbis Acutis Infantum, by Walter Harris, M. D. ; Lond. 1689, p. 22. 



DIGESTIVE SYSTEM. 179 

One of the causes of this change is diet. The milk of the 
female of all tribes of animals is affected by this cause, and an 
alteration in its nature and qualities will arise from a change 
made in the food. Experiments have been made on the suck- 
ling bitch, by substituting vegetable substances for the natural 
nourishment. Milk yielded by the animal under this change 
acquired all the properties of milk secreted by the ruminantia, 
readily undergoing spontaneous separation, and coagulable by 
the usual agents. The same animal was fed with raw flesh 
alone : the effect of this was soon apparent in the diminished 
quantity of milk, in its decided alkalescent properties, and in its 
resistance of spontaneous coagulation.* Here we have a stri- 
king evidence of the change effected on the lacteal secretion, 
by the alteration in the food alone; how much more liable 
must the human female be to a change in this secretion, whose 
diet is so variable, and who is exposed to so many other causes 
which materially influence the process of digestion. 

Indolence and luxury very materially vitiate the qualities of 
milk, as is evident in daily observation. Too free indulgence 
in eating is a frequent cause of a diminished quantity or an al- 
tered quality of the milk in wet nurses, who seldom possess 
that affection for their little charge, which would cause them to 
deny and regulate their appetite, that the milk may be less heat- 
ing and less irritating. The use of stimulating liquids is also 
common among them; and although there may not be suffi- 
cient used to cause ebriety, yet the secretions are always 
more or less impaired by a too frequent resort to stimulants, 
under the idea that the condition of the nurse, while suckling, 
needs the invigorating influence of alcoholic drinks. 

Another cause is the age of the milk. When, from neces- 
sity, a child recently born is nursed by a female who has 
been delivered some months, the infant rarely thrives, its di- 
gestive powers not being sufficiently vigorous to digest the 
milk abounding in nutritious qualities, as it almost always does 
at this period ; for after the fourth or fifth month, the relative 
proportion of the sugar and caseous matter are considerably 
increased, and a proportionate increase of vigour in the digestive 
system is requisite to carry on the process of nutrition. 

From a number of experiments made by M. Payenf on the 
physical and chemical properties of milk, it appears that its 
density generally increases with the remoteness from the time 
of parturition, and that the relative proportion of caseum was 
increased one third in a female eighteen months after confine- 
ment. 

* V. Kenedy on the Management of Children; Glasgow, 1825, p. 80. 
t Journal de'Chim. Medicale, de Pharm., etc., March, 1828, p. 118. 



180 DISEASES OP CHILDREN. 

The child may also suffer from the same cause, even when 
nursed by the mother from birth, from being suckled too long ; 
for after a year the milk has undergone a considerable change. 
It may also exhibit the effects of protracted suckling, even at 
an earlier period than this. The effects of long continued lactation 
are said to extend much farther than the digestive system ; and 
it has been remarked, that cerebral affections will arise from 
this cause. The digestive organs, however, are always the first 
to suffer from deterioration of the milk, arising from whatever 
cause it may. 

The return of the catamenial discharge will also produce an 
alteration in the qualities of the milk, and thus be a cause of 
suffering to the child. Purging is a very uniform effect of 
suckling, while menstruating; the alvine evacuations also being 
remarkable for their fetor. It appears to arise from the milk 
being overcharged with salts, and deprived of its nutritious in- 
gredients, by which it acquires purgative qualities. M. Retzius 
has detected free phosphoric and lactic acids in the colouring 
matter of the menstruous blood. Milk, therefore, during men- 
struation, is deprived of some of its important constituents. 
The excitement of the uterine system, arising from pregnancy, 
will also alter the qualities of the milk. A child, therefore, 
should never be nursed under circumstances where nature has 
so evidently pointed out the course to be pursued by the altera- 
tion and deterioration of the milk. 

A passionate or irritable temper, frequently indulged, is also 
another cause of the vitiation of the milk; so also is anxiety, 
grief, or any mental distress or preying affliction. Even a ner- 
vous temperament, by which a woman is predisposed to mental 
excitement from slight causes, will not fail to alter the qualities 
of the milk. Disease in every form has doubtless an immediate 
effect on the secretion of milk, and in acute diseases it is almost 
entirely suspended ; but the alterations it undergoes in its con- 
stituent principles have not yet been ascertained by experi- 
ments. The milk of the cow in tuberculous consumption has 
been analyzed, and found to contain a large portion of phosphate 
of lime. This may probably be the case with other mamiferous 
animals, and certainly demands the attention of physicians, both 
as regards the fact in relation to the human female, as well as 
the effect of this salt upon the digestion of young infants. 

Indigestion may also occur from too violent exercise given 
to the infant immediately after sucking, by the common practice 
of jolting on the knee. Rest, for some time after eating, is a dic- 
tate of nature, observed by all animals at every age ; the in- 
fluence of the necessary nervous energy should in no wise be 
diverted from its proper place of action. 



DIGESTIVE SYSTEM. 181 

The irritability of teething may be a cause of indigestion, 
and predispose the child to the disagreement of the food ; or 
rather, the change in the digestive system generally, arising 
from the developement of the muciparous glands, which at this 
period are greatly enlarged and highly sensitive. 

As the child advances in age, one of the most frequent causes 
of this disease is improper food, of an artificial kind, the tender 
and highly sensitive mucous membrane being easily excited by 
such kinds of food as possess much irritating qualities. A sudden 
change, also, from the bland food furnished by the breast, to any 
substantial aliment, will almost always be followed by a great 
disorder of the digestive organs and bowels ; while a gradual 
change to the same kind of food will not usually be followed 
by similar consequences.* There is also an error very often 
committed, of giving the child too much food. Indeed, there are 
few children injured by abstinence, but thousands are made 
sick by over feeding. The digestive organs are taxed beyond 
their ability, and the child, instead of thriving under the load 
of nourishment, pines away, and at last falls a victim to the mis- 
taken attentions of its nurses. These are most likely to occur 
at the usual time of weaning, by the change in the food at this 
period, and have been long known in England by the popular 
name of weaning brash. 

Among the most indigestible articles for children, are dried 
and preserved fruits and confectionary, of which children are 
remarkably fond. The smallest quantities of these articles are 
not free from danger, for convulsions have been caused by the 
irritation produced by the eating of a few raisins. All fruits, 
whether fresh or dried, with a thick skin, are injurious to chil- 
dren. The seeds also form an additional source of injury to the 
mucous membrane of the digestive organs. Therefore, fruits 
abounding in hard seeds, where these are necessarily eaten 
with the pulp, as currants, grapes, blackberries, etc., should be 
avoided. 

Unripe fruits of every kind are particularly injurious, and are 
scarcely ever digested, both from the hard and unyielding na- 
ture of the parenchyma, and from the acid with which they 
abound. Whenever they are much used, colic and diarrhoea, 
the latter often becoming chronic, with inflammation of the 
mucous membrane of the intestines, are almost certain to ensue. 
Of ripe fruits, pears and plums are the most indigestible, 
the pulp often remaining for a long time undigested in the sto- 



* Indigestion from this cause has been very elaborately considered by Dr. John 
Cheyne, under the name of Atrophia ablactatorum : Essays on Diseases of Chil- 
dren ; Edinburgh, 1802. 



182 DISEASES OF CHILDREN. 

mach. Cherries, particularly, on account of the skin, are less 
digestible than many fruits ; and even the sweetest kinds contain 
a quantity of acid, which makes them generally objectionable 
for children, especially those that are delicate. The membra- 
nous part of oranges should never be allowed to be eaten, it 
being almost insoluble in the gastric fluid. 

Esculent roots, such as are used for food, as carrots and 
turnips, are rarely injurious ; but those that are used merely as 
condiments, as onions, garlic, horse-radish, radishes, etc., almost 
always cause indigestion, colic and flatulency, in children who 
are unaccustomed to their use. 

Semeiology. — The first symptom of indigestion in infants at 
the breast, is a paleness of the face, with peevishness and fretful- 
ness. They cry continually until they are placed at the breast, 
when they suck with greediness, without, however, appearing 
to have their hunger appeased. Far from thriving with the 
nourishment they receive, the more they receive, the more they 
suffer from indigestion, frequently vomiting their milk in a 
curdled state, a symptom very common in young infants, 
when there exists an excess of acid. Under these circum- 
stances, there is formed a complete curd, more or less dense, 
according to the degree of acidity in the stomach. At other 
times there may exist vomiting, with deficiency of acid. In this 
case the milk is generally returned unchanged, and the vomit- 
ing is almost always attended with nausea, as is evident from 
the paleness of the face, and the efforts to resist the vomiting. 

In all the symptoms there is a remarkable absence of inflam- 
matory action, the children sinking from inanition, and dying 
apparently from starvation. Such cases are more frequently 
seen in the foundling hospitals in Europe, where the mortality 
from this cause is very great. 

In those cases where indigestion arises from improper arti- 
ficial nourishment, given to the child either before or at the 
time of weaning, nature in the first instance makes an effort to 
relieve the system, and vomiting and purging are usually 
found to exist at the commencement of indigestion, from im- 
proper food, or from food taken in inordinate quantity. Colic 
and spasm not unfrequently attend indigestion, and convulsions 
may often result from the sympathetic irritation caused by the 
presence of indigestible matters. 

Colic is a very distressing symptom, and in some infants will 
occur daily for a long period ; the violence of their cries, and 
the writhinsrs and contractions of their limbs, attest the severity 
of their sufferings. When violent or long continued, it is 
attended with evident flatulency, and a tympanitic condition of 
the abdomen. There is also evident acidity in the prima? vise, 



DIGESTIVE SYSTEM. 183 

as appears both from the odour of the breath, and the green 
colour of the stools ; the evacuations of which, as well as the 
discharge of gas, either passing with them, or by eructations, 
will almost always relieve a paroxysm of colic. 

The immediate cause of the pain is the distention of the 
intestine by gas, produced, doubtless, by some obstruction to 
the passage of the contents of the bowels. The opinion of Dr. 
Abercrombie as to the cause of this obstruction, appears, in the 
generality of cases in young children, to be the true explana- 
tion, if we may judge from the effects of the remedies which 
are usually successful in its treatment. He refers the condition 
of the intestine to atony, or loss of power in the muscular fibre 
in the part affected, while the parts above and below it still 
retain their normal action. His inference is, that the part 
beneath the distended portion is merely collapsed, and not in a 
state of spasm, and is not the seat of the pain ; but that the 
portion which suffers over distention, from the accumulations in 
it, is the part which is the seat of the distress.* There are 
cases, doubtless, of spasm of some portion of the intestinal tube, 
for the acrid matters, by their irritation, will sometimes pro- 
duce a contraction of the muscular fibre ; but it does not follow 
that this spasmodic contraction of the muscular fibre is always 
essential to the disease, as Dr. Cullen has maintained it to be in 
all cases. From the relief usually obtained by the use of mild 
stimulants in the colic of infants, and which have become so 
popular, as in many instances to be wrongly applied, it would 
appear that the loss of power in the muscular coat was the real 
cause of the distressing colic pain. The truth probably lies be- 
tween the two ; and although, in the generality of cases, this pain 
in infants may be regarded as arising from the relaxed condi- 
tion of the muscular fibre of some particular portion, yet it may 
be complicated with a spasmodic action, and dependent on this 
condition, either altogether or in part of the adjoining portion. 

Colic may arise from other causes than indigestion and flatu- 
lency, as inflammation, invagination, hernia, or imperforation of 
the anus in new-born infants. The diagnosis may be in general 
easily made, with a little care. The absence of fever, the relief 
of the pain by pressure, and the natural state of the pulse, to- 
gether with the absence of the peculiarly painful expression of 
face which attends inflammation of the bowels, will enable us to 
distinguish colic from enteritis. 

Should improper food, or an inordinate quantity of appro- 
priate food be continued, the undigested matters will pass into 

* Pathological and Practical Researches on the Diseases of the Stomach and 
Intestinal Canal ; London, 1818. 



184 DISEASES OF CHILDREN. 

the bowels unaltered, causing the form of diarrhoea known by 
the name of lientery, and considered by authors as a distinct 
disease. In these cases the undigested aliment becomes an 
irritant to the delicate mucous membrane, by which the peri- 
staltic motion of the bowels is increased, and their contents 
rapidly urged forward. It is so clearly one of the symptoms 
of indigestion, and depending on that disease for its existence, 
that it is not, on this account, here regarded in any other light. 

After the irritation of the bowels has once been excited in 
children that have been recently weaned, and subjected to a 
new kind of food, it may continue until other organs are in- 
volved. The liver especially becomes disordered in its func- 
tions, and the alvine discharges exhibit the presence of bile, 
varying in colour from a yellow to a grass green. This condi- 
tion of the liver, being doubtless caused by the change of food, 
becoming a violent stimulant to the upper portions of the in- 
testines, and the transmission of irritation by continuity of tissue. 
If this had been an accidental or transitory irritation, the af- 
fection would have cured itself; but the frequent repetition 
of the irritating cause keeps up the disease, and prevents the 
liver from discharging its normal functions.* Should the food 
which causes these symptoms of indigestion be still given to 
the child, the skin will become dry, the abdomen tumid, the 
vomiting and purging incessant, while rapid emaciation takes 
place. The child is remarkably fretful, and apparently suffers 
from pain, but is usually too young to express the sensation. 
The tongue for the most part is clean and moist, or is covered 
with a slight coating of white secretion, which often assumes 
the form of the concrete exudation, so common in stomatitis. 

Although purging is a very common attendant on severe 
cases of indigestion, yet it often alternates with a constipated 
condition. This latter symptom has been remarked to occur a 
few days before death. 

Indigestion is sometimes protracted for a month or more, 
when the child becomes excessively emaciated, and dies from 
exhaustion, produced by the incessant action of the bowels. 

Morbid Anatomy and Pathology. — Traces of inflammation 
are rarely found in the stomach or bowels. On the contrary, 
they are in an exsanguined state, and even transparent, while 
some portions of the intestines are much distended with gas. 
The mucous membrane is without colour through its whole 
extent, and is found softened ; an alteration which may occur 
without inflammation. Although there may have been seen in 
some instances traces of inflammation, yet the white softening 

* Cheyne, Second Dissertation, p. 25. 



DIGESTIVE SYSTEM. 185 

is the most frequent alteration.* In addition to the gas, with 
which the intestines are distended, there is often found in them 
a quantity of white frothy matters. 

The want of colour is almost always the first degree of a 
species of softening, which should not be confounded with the 
effects of inflammation. The disease described by M. Cruviel- 
heir, under the name of gelatiniform disorganization of the 
mucous membrane of infants, would appear, from the detail of 
symptoms, to be a violent species of the disease now under 
consideration. f M. Duges, in his Manuel d'Accouchemens, in 
speaking of a similar affection, remarks, that he has found the 
interior coat of the intestines covered with, a white mucus, of 
a pulpy consistence, and bearing a resemblance to imperfect 
chyle, and which inattentive observers might mistake for the 
softened mucous membrane. The mucous follicles, he observes, 
could be still seen on the intestinal surface. 

The traces of red colour which are sometimes found in the 
intestines of very young infants, who perish with all the symp- 
toms of want of nutrition, are nothing more than the normal 
change, arising from the natural congestion of the part ; a con- 
dition always existing in them, as noticed by the French 
pathologists. 

In the indigestion occurring at the time of weaning, and 
described by Dr. Cheyne under the name of atrophia ablacta- 
torum, the intestines, in every instance, were found in a state 
of intussusception ; and that it was spasmodic and not inflam- 
matory in its nature, was evident from the ease with which 
the contained part of the intestines was disengaged from the 
portion which formed the sac. In addition to these appear- 
ances, the liver was remarkably firm, larger than natural, and 
of a bright red colour, and the gall bladder, much enlarged, 
contained green bile.J 

Treatment. — When it is discovered that the milk of the 
nurse disagrees with the child, a careful attention to her diet 
becomes necessary ; and all such articles as are observed to 
disagree with the stomach must be rejected as food, for an 
imperfect assimilation will ensue, and the milk will necessarily 
partake of the change. It is difficult to point out strictly those 
which should always be avoided ; but as a general rule, she 
should shun the use of all ascessant fruits, fruits preserved in 
vinegar, cabbage, cheese, etc. ; and also, by diminishing the 
quantity of food taken when the appetite is good, allay the 



* Billard, Diseases of Infants, p. 289. t Loc. Cit. 

t Cheyne, Op. Cit., p. 22, et seq. 
24 



186 DISEASES OF CHILDREN. 

slight febrile action that may arise, which diminishes and impairs 
the secretion of milk. It not unfrequently occurs where the 
appetite is good, and freely indulged, without any symptoms of 
indigestion arising; an excited state of the blood-vessels will 
take place, a condition uniformly connected with diminished 
secretion. So, also, all stimulating liquors, so frequently given 
to promote the secretion of milk, ought to be avoided, except 
under peculiar circumstances of debility. Abstinence, therefore, 
will often, in robust individuals, who freely indulge their appetite, 
be a means of promoting the secretion of milk ; and where 
there exist the ordinary symptoms of plethora, such as fulness 
about the head, headache, or a frequent full pulse, it may be 
necessary to abstract blood by the lancet, and to administer a 
purgative. These means, joined to the use of a light diet, con- 
sisting principally of well boiled farinaceous substances and 
milk, will often restore the secretion, and impart to it the pro- 
per consistency. 

Where, on the contrary, there exists a general debility of the 
system, without any organic affection, a stimulating diet may 
be necessary. This, however, is seldom the case ; a too great 
eagerness for over feeding is the usual fault with nurses, and 
there is scarcely a necessity on the part of the medical attendant 
for prescribing this course. 

In the treatment of indigestion from weaning, Dr. Cheyne 
relied mainly on small doses of calomel, half a grain night and 
morning, preventing its too powerful operation on the bowels 
by enemata of laudanum. 

One of the most common attendants on indigestion is vomit- 
ing, accompanied in most cases by acidity of the stomach, 
flatulency, pain, and sometimes diarrhoea. 

When obstinate vomiting arises from the bad quality of the 
milk, occurring immediately on the child's sucking, nothing but 
an improvement of the milk, or some permanent change, either 
by the employment of another nurse, or the adoption of another 
kind of food, will be necessary. As was before remarked, the 
protracted lactation and the disorder of the system, from the 
action of the uterus, arising either from the return of the menses 
or pregnancy, will produce an alteration in the quality of the 
milk. It has been remarked, that nurses who are subject to 
nervous affections, secrete milk having the appearance of the 
white of an egg. 

Although acid is generally present in the matter vomiled by 
young infants, yet there are instances in which this appears to be 
unconnected with the vomiting ; but an irritated state of the 
stomach is the only cause to which it can be assigned. In 
such cases, ipecacuanha and rhubarb will be found a valuable 



DIGESTIVE SYSTEM. 



187 



prescription.* Dr. Eberle recommends small doses of calomel 
and ipecacuanha to allay gastric irritability,! in conjunction 
with a stimulating poultice or plaster to the epigastrium. This 
may be made with mustard in flour, mixed with rye meal or 
wheat flour, and is one of the most efficient counter-irritants. 
The effect of the application of mustard should be carefully 
watched, for very severe cutaneous inflammation may be the 
result of allowing the mustard to remain on too long ; blistering 
and sphacelation have also sometimes followed a careless 
application of sinapisms. From fifteen to twenty minutes is 
the proper time for the mustard poultice to remain on ; and in 
children of great irritability, a piece of fine gauze ought to be 
interposed. Where it is not deemed necessary to produce a 
speedy impression by the use of these stimulating poultices, 
an ordinary poultice may be mixed with a small quantity of 
the powdered mustard, in the proportion of about four ounces 
of the former to a drachm or two of the latter ; or flannels 
may be dipped in a weak infusion of mustard, and applied over 
the stomach. Should there be much inflammation or pain fol- 
lowing the application of mustard, a little fresh cream or muci- 
lage of slippery elm may be applied to allay their violence. 
•One of the best means of treating this affection, in addition to the 
means already mentioned, is by producing a revulsion on the 
lower portion of the intestines, by means of stimulating ene- 
mata ; half a teaspoonful of salt, in a gill of warm water, is 
an excellent one for this purpose, Dr. Eberle speaks highly 
of the use of morphia, applied externally, by means of simple 
cerate ; one or two grains of the former, mixed with a plaster 
of the latter, will often have a sufficient narcotic influence to 
allay this morbid vomiting, arising from an inordinate irrita- 
bility in the mucous membrane of the stomach. 

Vomiting may also occur when there exists a deficiency of 
acid in the stomach. It is well known that there is always 
present, during healthy digestion, a quantity of free acid, which, 
according to the experiments of Beaumont and Lauret, is the 
hydro-chloric. From the uniformity of its existence, and from 
the suspension of the process of digestion, by the neutralization 
of this acid, it would appear to be necessary to healthy diges- 
tion. When there exists a deficiency of acid, it may be 
known by the milk remaining a long time in the stomach before 
it is vomited ; the child in the mean time exhibiting every sign 



♦ ~Bc Pulv. Ipecac, gr. j. 

Pulv. Rhei., gr. xij. M. 
Divid. in pulv. No. iv. 
One three times a day. 



t fy Hydr. Subm., gr. iss. 

Pulv. Ipecac , gr. j. M. 
Divid. in pulv. No. vi. 
One e\ery hour or two. 



188 



DISEASES OF CHILDREN. 



of nausea, and discharging the milk in an unchanged condition. 
A few drops of hydro-chloric acid, in a little water, will be 
found a very efficient remedy, as it supplies the deficiency of 
the natural acid ; and in cases where the experiment has been 
tried in adults, the restoration of the process of digestion, 
which had been arrested by neutralizing the acid, was quickly 
affected by administering it. Lemonade is also an excellent 
prescription in such cases. Madeira wine, either diluted, or in 
the form of whey, will also be found to be highly beneficial, 
especially where there is any debility or depression of the 
system. 

Often the matters ejected will possess a decided acid odour, 
and the child will not be relieved by the vomiting, but continue 
pale and distressed. When these symptoms are present, there is 
probably some caseous matter still remaining in the stomach, 
and a gentle emetic of ipecacuanha will be necessary to re- 
move it. Very distressing symptoms often arise from this 
cheesy matter remaining undigested. The emetic should be 
followed by a small dose of calomel, when there is evidence of 
a derangement of the biliary secretion or the hydrargyrum cum 
creta, which may, in cases of great irritability of the bowels, 
and tendency to diarrhoea, be combined with Dover's powder. 

Vomiting, occurring in those children who have been either 
over-fed, or who have been fed with improper food, is generally 
attended with a quantity of acid. Under these circumstances it 
will be necessary to change the food, and where the child is 
weaned, to mix some prepared arrow-root or barley with almost 
any kind of weak broth. Barley water, in which gum arabic is 
dissolved, or milk diluted with rice water, and combined with a 
small quantity of chicken water, or other weak solution of animal 
substances, will arrest the tendency to acidity arising in those chil- 
dren who are fed principally on milk or farinaceous substances. 

Lime water, mixed with an equal quantity of milk, a tea- 
spoonful of which to be given every half hour, I have found to 
be the best to allay inordinate vomiting, arising from the exist- 
ence of acidity in the stomach. Where there exists costiveness, 
magnesia is the most proper antacid that can be administered, 
and especially when combined with super-carbonate of soda. # 

After the contents of the bowels have been removed, the 
irritability of the stomach may be calmed by a little tincture 
of opium or tincture of camphor, f 



* ]J: Magn. Calc, gr. x. 
SuptC. Sodee, gr. v. 
Sacchar. Albi, q. s. M. 
ft. Pulv. No. iv. 
One to be given every three or four 
hours. 



t *fy Camphoree, gr. ss. 

Mucil. g. Acaciae. gij. 

Vini Opii, gt. i. — ij. M. 
A teaspoonful every hour or two. 



DIGESTIVE SYSTEM. 



189 



In the indigestion of children there not unfrequently exists a 
severe purging, which it will be necessary to arrest ; and this 
should be done by astringent and anodyne remedies, if the com- 
posing mixture just mentioned for an irritable stomach should 
fail in effecting it.* An anodyne enema may first be tried, 
made with two or four drops of the tincture of opium in two 
ounces of prepared starch, or infusion of flaxseed. 

External stimulation of the abdomen is a very valuable aux- 
iliary to the treatment, effected either by simple friction with the 
hand, or by means of heated flannel or warm spirits ; if the latter 
be used, care should be taken, by sufficiently covering the part, 
to prevent evaporation, otherwise the object would be defeated, 
and cold applied instead of heat. 

For the relief of a paroxysm of colic, in addition to the gene- 
ral principles detailed for the treatment of indigestion, on which 
it depends, it will be necessary more especially to resort to 
the use of those remedies which will remove the more imme- 
diate cause of the affection ; such as small and repeated doses 
of magnesia, should acidity be evidently, as it in most cases is, 
connected with it. And where it appears to be dependent 
on debility in the organs of digestion, a mild stimulant will 
often be found the best remedy for its relief, as an infusion of 
■catnip, fennel or anise seed. These may advantageously 
be combined with an antacid. Dr. Eberle advises twenty 
grains of bi-carbonate of soda, dissolved in an infusion of vale- 
rian root, in the proportion of one ounce to a pint, with a drachm 
or two of ginger syrup ; a teaspoonful of which may be given 
several times a day, to an infant from one to three months old ; 
or the annexed formulae maybe used.f In violent and sudden 
attacks of pain, it will be necessary to resort to remedies which 
will afford more prompt relief; that recommended by Dr. 
Dewees is one of the most effectual. J An enema of an infusion 
of catnip or camomile flowers will often give immediate re- 
lief to a paroxysm of colic, or a laxative one with tincture of 



* ft Aq. Cinnam., §j. 
Mist Cretse, gss. 
Tinct. Kino, 3ij. 

" Opii, gtts. viij. 
Syrup. Simpl., 3ij. M. 
One or two teaspoonsful every two 
hours, until the purging be checked. 
t ft Magnesia, gr. iij. 
Sem. Anisi.Cont. 
Sem. Foenic. Cont., aa gr. ij. 
Croci, gr. j. 
Sacchar. Alb., gr. vij. 
One half to be given at once, and the 
remainder in half an hour. 



ft Magnes., gr. xv. 
Pulv. Rhei., 3j. 
Aqua. Funiculi, jfiss. 
Syrup. Rhei., §ss. 
A teaspoonful three or four times a 
day. 

t ft Magn. Calcin., 3j. 

Tinct. Assafoetid., gt. lx. 
Tinct. Opii., gt. xx. 
Aqua? Font., fj. 
Dose, twenty drops for a child from 
two weeks to a month old; ten drops 
more to be given in half an hour. 



190 DISEASES OF CHILDREN. 

assafoetida. Fomentation of warm water applied to the>bdo- 
men, or immersing the feet in warm water, will also be found 
useful adjuncts to the general treatment. 

It has been made a serious question with some physicians, 
whether, in case of the inability of the mother to nurse her in- 
fant, an artificial course of feeding is not preferable to the 
employment of a wet nurse. Baldini, in Italy, Betzski, in 
Russia, Raulin, Desessarts, in France, citing the custom of the 
Scythians among the ancients, and that of the Russians and 
Danes among the moderns, have decided in favour of the arti- 
ficial method.* Armstrong, also, after having for a number of 
years filled the office of physician to an institution where many 
infants were received, in London, recommended the nourishing 
the infant by the spoon. On the other hand, Thouret, Auvity, 
and others, have maintained that the natural feeding possesses 
incalculable advantages over the artificial, from a number of 
experiments made in public hospitals. There can scarcely exist 
a doubt as to the advantage of a proper wet nurse over the 
other method, as the nourishment she can afford possesses the 
closest resemblance to that which should constitute the nourish- 
ment of an infant. 

When it becomes necessary to remove the infant from the 
mother's breast, care should be taken in the selection of a healthy 
young woman to take the situation of nurse. The best nurses 
are those who possess all the evidences of good health. The 
tongue clean, teeth and gums sound, indicating healthy diges- 
tion. The breath free from any unpleasant odour. The sur- 
face of her body free from eruptions, and the insensible perspi- 
ration inoffensive. Her breasts smooth, firm and prominent ; 
the nipples well developed, rosy coloured, and easily swelling 
when excited. The milk should flow easily, be thin, bland, of 
a bluish tint and of a sweet taste ; and when allowed to remain 
undisturbed, be covered with considerable cream. 

It is said that women of a brown complexion generally have 
an abundance of milk, and of an unusually rich quality ; and 
that those of a fair complexion have less substantial nourish- 
ment, and that it tends much to keep the bowels relaxed, pro- 
bably from abounding in a greater proportion of salts. 

Females, when giving suck, should use moderate and regular 
exercise in the open air, and subsist on light, but generous diet, 
composed of a proper mixture of animal and vegetable sub- 
stances, regard being had to their usual manner of living. It 
may, and often is necessary to excite the flow of milk, by the 
use of additional fluid nourishment, which may sometimes 

* Carrault, Guide des Meres, p. 78; Paris, 1828. 



DIGESTIVE SYSTEM. 191 

require to be made slightly stimulating. Dr. Struve recom- 
mends the drinking of a glass of cold water every morning. 
He also gives the following prescription, when a little stimula- 
ting drink is necessary in women who have been much ex- 
hausted by suckling : Two parts of milk should be made to 
boil over a slow fire, to which is added one part of well fer- 
mented beer, previously boiled. Sugar may also be added, 
and the beverage should be taken cold. 

From the impossibility of obtaining a good nurse for the in- 
fant, it will sometimes be necessary to resort to artificial feed- 
ing; when such food, the constituents of which bear the greatest 
resemblance to the maternal milk, must be provided. 

Milk of all animals is a white, bland fluid, of greater specific 
gravity than water, consisting of serosity, curd, or caseous 
matter, and cream — or, to speak more philosophically, of water 
holding sugar, soluble salts, and some traces of azotic matter 
in solution — caseum, and fatty matter ; the solid parts being about 
fourteen per cent. 

There are, however, different proportions of these elements 
in different classes of mamiferous animals ; and each kind yields 
milk, which can be distinguished by its peculiar taste, as well 
as by the proportion of its constituent parts, on a chemical 
examination. 

The milk of the human female contains more whey, or sero- 
sity with soluble salts, than that of the cow, goat or sheep, and 
more sugar than that of any other animal. It contains less 
caseum than the milk of the goat, sheep, cow and ass ; and 
also less butter than that of the sheep, cow or goat, but more 
than the milk of the ass. Human milk is whiter than cow's, 
and appears to be acid, on the application of the proper tests. Its 
composition, however, varies remarkably in djfferent individuals. 
In some, where there is an irregular portion of whey, and but 
little or no caseum, it yields more or less cream, but never can 
form butter, even with considerable agitation ; in this case, it 
will not coagulate on the addition of acid. In other cases, sub- 
stantial cream is formed, and after moderate agitation, yellow 
butter, of a firm consistence, may be obtained ; this milk is 
coagulable by acids, and a white solid curd separates from it. 

The principal constituents of the milk of the five d.fferent 
animals, with that of the human female, which have been sub- 
mitted to examination, viz. the sheep, goat, cow, ass, and 
the mare, it appears generally exhibit very uniform propor- 
tions. In the first three, all ruminating animals, the caseous 
matter and butter predominate, as has been already remarked. 
The other two, which are herbivorous animals, have their milk 
very much resembling that of the human female, in the abun- 



192 



DISEASES OF CHILDREN. 



dance of whey and sugar. Therefore, if it were possible to 
procure a regular supply of the milk of these animals, it would 
be decidedly the best substitute we could obtain for the mother's 
milk ; but as this is almost an impossibility, it will be necessa- 
ry to prepare an artificial substitute from cow's milk, which is 
always at hand, and so dilute it and combine it, as will make it 
more closely resemble the natural nourishment of the infant. 
It should be prepared, by adding at first an equal quantity of 
rice water, and a little of the purest crystalized sugar. The 
infant will require no other nourishment than this, which may 
be altered gradually, so that at the end of the first month to 
consist of two parts of milk to one of rice water. An infant 
will scarcely ever require any other nourishment, until about 
the fifth or sixth month, when thin pap, made by pouring boil- 
ing water on stale bread, and combining it with fresh cow's 
milk, may be given. 

While the child is still fed with diluted milk alone, especially 
in the early part of its life, the use of the sucking bottle is de- 
cidedly preferable to feeding with the spoon, as the exertion of 
sucking evidently promotes the salivary secretion ; a very ne- 
cessary process at all ages. Care should be taken that the 
vessels be well cleansed by washing them with boiling water, 
that nothing be allowed to remain which will cause acidity ; 
this should always be done immediately after the child is fed. 

Although, as a general rule, the young infant will not require 
any thing more than milk diluted until about the time of the 
appearance of the first teeth, yet there may be, and often there 
are circumstances which demand a more nourishing course of 
diet ; and in case the infant does not appear to thrive, or is 
affected with diarrhoea, or any other symptom dependent on 
indigestion, it would be well to vary the food, and gradually 
accustom it to the use of different and more substantial nourish- 
ment. The milk may be thickened with arrow-root, potato- 
starch, sago, etc., and its effects carefully watched. With all 
these substances sugar should be plentifully mixed ; it is the 
condiment which best agrees with the digestive organs of in- 
fants: indeed, it affords a vast degree of nourishment to all ani- 
mals, at every age, as is evident, during the season for gathering 
the cane, when both the negroes, oxen, and mules, show the 
evidences of its nutritious effects on their systems. 

As the infant advances in age, it is evident that an alteration in 
the consistence of its food is necessary, preparatory to a final 
discontinuance of nursing ; and the substances just mentioned 
ought to form a prominent article of food about the time of the 
appearance of the first teeth. It may also be varied, by giving 
some light animal infusion, either of beef or chicken, with the 



DIGESTIVE SYSTEM. 193 

fat removed. The different articles of food must be used, and 
that generally adopted which is found the least disposed to be- 
come acid. 

This is the proper place to speak of the subject of wean- 
ing, as one of the means necessary for the treatment of indiges- 
tion in infants, where it arises from the impaired quality of the 
milk, from whatever cause. The age of the milk will also 
make it necessary to wean the child, even though there should 
not be decided symptoms of sickness ; for it has been remarked 
by some physicians, that a general debility of the system may 
arise from the continuance of suckling too long, and also that 
those children whose nursing is protracted are likely to suffer 
from hydrocephalus. 

The period for weaning the child depends in some measure 
on the constitution of the mother, and that of the child. The 
condition of the milk, as has already been observed, may render 
it necessary even before the appearance of the teeth, or their 
tardy appearance may render a protracted suckling necessary ; 
but as a general rule, the child ought not to be kept at the breast 
beyond a year ; it may also, in the majority of instances, be 
weaned about the ninth or tenth month. A French writer, 
Baillon, recommends that infants be suckled at least for two 
years and a half; another, Madame Lerebours, goes still farther, 
and advises suckling to be continued until the fifth year.* 

If the child has been gradually accustomed to a change of 
diet, weaning will not be found to be a process of much diffi- 
culty ; and if, after weaning, the food still consist principally of 
milk, thickened with arrow-root, ground rice, etc., there will be 
little to fear from indigestion. Cow's milk, therefore, should 
invariably constitute the chief ingredient in the food of children 
for some months after their removal from the breast, occasion- 
ally giving some simple animal broth. More solid nourish- 
ment will be needed when the molar and canine teeth have 
made their appearance ; and food of a greater variety, and 
containing more nourishment, must be given when the diges- 
tive organs have acquired an increase of vigour, and are in a 
condition to allow of its reception. 

When a sufficient number of teeth have appeared to enable 
the child to chew, a moderate quantity of animal food may be 
used at dinner, with the usual vegetables. The breakfast of 
children ought generally to consist of milk in some form ; and 
for young children, should be added to a little bread pap. About 



* V. Carault, Guide des Meres; Paris, 1828. On this subject the author remarks, 
" C'est bien dormer prise & la plaisanterie, mais l'auteur est d'un caractere trop 
respectable pour qu'on se le permette." 

25 



194 DISEASES OF CHILDREN. 

the fourth year, bread and undiluted milk may be given, and 
the child's inclination in some degree consulted. For supper, 
which ought to be taken about an hour before the child is put 
to bed, the same as is used in the morning. 

There is often great anxiety on the part of mothers on the 
subject of insufficient nourishment, which their children obtain 
from light diet, so often recommended by physicians. There 
is, however, little danger of children suffering from this 
cause ; indeed, I never saw an instance. On the contrary, num- 
bers have been brought to the grave by too frequent feeding, 
and the large quantity of food given. The works of Syden- 
ham, Boerhaave, and his commentator. Van Swieten, contain 
several instances of persons who, from necessity, adopted a 
milk diet, and retained their ordinary vigour. "Sufficient 
nourishment" was afforded to a rheumatic patient of the first 
named writer, by a " little bread and a gallon of whey," taken 
during the day.* Van Swieten quotes Aretseus' remark, that 
milk is more suitable to children than any other food ; and that 
if any one will drink milk enough, he will need no other food. 
The illustrious Boerhaave himself, it is said, for a long time took 
scarcely any other nourishment than whey. 

It is by no means intended, by these remarks, to recommend 
any one course of food to the exclusion of all others ; man is 
omnivorous, and experience should be the only guide. It is 
also impossible for the experience of one individual to be the 
rule by which another is to be directed in his diet. This sub- 
ject is one on which it is hardly possible to form any theory ; 
for the facts which are familiar to us in relation to it, being 
liable to be controlled and influenced by a great variety of 
conditions, every thing that may thus influence it should be 
taken into the consideration in each case that comes under our 
notice. 

DIARRHOEA. 

This disease, in some form or other, is extremely frequent 
among children, both as a functional disorder of the intestinal 
tube or its appendages, and as a symptom of organic affec- 
tions. The former class is what we shall at present notice. 

Several varieties of diarrhoea are considered by authors ; but 
as some of them are clearly symptoms of indigestion — as that 
form in which the food is passed unchanged, known by the 
name of lienteric diarrhoea, and that attendant on weaning — 
those only, which, from the nature of the evacuated matters, 
evidently arise from the deranged functions of the intestines, 

♦ Epist. to Dr. Brady, p. 328. 



DIGESTIVE SYSTEM. 195 

or parts connected with them, and not from gastric indigestion, 
will be considered as belonging to this class of diseases. 

The nature of the evacuations in diarrhoea are very varying, 
even in individual instances, both at the same period and du- 
ring the course of the disease ; yet the prevailing characters 
which they exhibit, has caused a classification to be made by 
practical writers — an arrangement well-founded, and of great 
use as points of general reference, even in the most compli- 
cated cases. 

There appear to be three varieties of diarrhoea : feculent, 
serous and bilious, as the predominating nature of the alvine 
evacuations indicates. All these may, however, pass into each 
other, and what at first would appear to possess the distinctive 
characters of one form, may, by a transfer of irritation, ulti- 
mately become of another character ; and in all the forms 
there is more or less mixture of bilious matter, rendering close 
examination of the alvine discharges necessary to detect the 
nature of the affection. This inspection of the fecal matter 
was the subject of much attention in former times ; and Hip- 
pocrates appears to have been greatly in the habit of close 
attention to this subject ;* and physicians of the present day 
would do well to imitate this practice of the father of medicine. 
These varieties are placed in the order of their simplicity ; 
and the first, or the simple form, very naturally first attracts our 
notice. 

FECULENT DIARRHOEA. 

This variety consists altogether of the ordinary feculent con- 
tents of the bowels, from an increase of their peristaltic motion. 
It precedes every other form of diarrhoea; for the ordinary 
contents of the bowels must first be evacuated, before the morbid 
changes in the secretion occurs, which are the distinguishing 
marks of other forms. 

Etiology. — One of the most common causes of this disease 
is the presence of acrid matters of the food, still imperfectly 
digested, or from irritating substances introduced into the intes- 
tines. In one sense it may be considered as the effect of indi- 
gestion, and therefore might be regarded as a symptom of that 
disease ; but the food may in reality be digested, although there 
may be acid or other irritating matters contained in the mass of 
the consents of the bowels, from a deficiency in its entire alter- 
ation, by which some chemical changes have occurred, ren- 
dering them a cause of excitement to the mucous membrane. 
Cold or wet applied to the surface of the body, constringing 
the skin, and thus directing the course of the blood to the in- 

♦ Aph. xiv., et seq. 



196 DISEASES OF CHILDREN. 

ternal surfaces, already predisposed to excessive action, from 
their constant natural action in the process of nutrition, will 
also produce a common diarrhoea in children ; but an inflam- 
matory affection is most commonly the result of this cause, 
and the disease is more likely to become of a mucous form. 
The retrocession of eruptive affections is also a frequent cause of 
diarrhoea, and is often a critical change of the disease with 
which a child is affected. Indeed, any cause which will pro- 
duce an increase of the ordinary peristaltic motion of the in- 
testines, will be followed by a diarrhoea, consisting of the 
ordinary fecal matters. Children, to the age of three years, 
are frequently attacked with simple diarrhoea. 

Semeiology. — It is almost always attended with a little nau- 
sea and abdominal pain, which disappear immediately on the 
passage of the feces, to return after a short interval. The 
evacuations are of the usual fecal appearance, although much 
more liquid than natural, and therefore it is easily distinguished 
from other forms of the disease, scarcely containing any of 
the morbid secretions which characterize them. 

Pathology. — In this mild form of the disease there exists 
merely a morbid degree of irritability or sensibility in the 
mucous membrane of the intestines, by which the fluid secre- 
tions are more abundantly formed and mixed with the contents 
of the bowels. The mucous membrane cannot be considered 
as in a state of disease; and as this variety itself is never fatal, 
no opportunity has been afforded to examine the pathological 
condition of the intestines. Protracted cases of feculent diar- 
rhoea cannot exist, without the nature of the affection changing 
its character, exhibiting either signs of other forms of diarrhoea 
or of dysentery ; and the pathological state arising from the 
change of the disease, w T ill be indicated by the alteration of 
the stools — by their colour, consistence, and other physical 
signs. These, together with the results of autopsical investi- 
gations, will come under our consideration when the other 
varieties of diarrhoea are discussed. 

Treatment. — This disease is often removed by the sponta- 
neous evacuation of the offending matter, on which its existence 
depends ; the morbid action ceasing on the complete discharge 
of the contents of the bowels. Should the occurrence, however, 
of diarrhoea be frequent and continued, it will be an evidence 
that the whole of the irritating substances have not been re- 
moved, and the interference of art will be necessary to prevent 
the occurrence of an inflammatory state of the mucous mem- 
brane, by the effectual removal of all the irritating causes of the 
disease. This should, in every instance, be effected by means 
of the most gentle and unirritating means, and such as will 
neutralize the acid, which in almost every case exists, and 



DIGESTIVE SYSTEM, 



197 



which is the principal source of irritation. Calcined magnesia 
neutralizes the acid of the stomach, without any extrication of 
gas, and a mild purgative salt is formed by the union ; this 
may be combined with rhubarb, a medicine peculiarly applica- 
ble to this disease, from its tonic influence. As a medicine for 
children affected with simple diarrhoea, rhubarb is of great 
value, from its astringent effect after evacuating the bowels. 
To disguise the taste, cinnamon is the best aromatic that can be 
selected, and may be used where there is no inflammation in 
the stomach.* When there are no evidences of acidity in the 
primae vise, castor oil or rhubarb, either alone, or combined 
with a small quantity of calomel, in the proportion of ten grains 
of the former to one of the latter, for a child of a year old, 
will be the most proper to remove the contents of the intes- 
tines. The officinal preparation of the syrup of rhubarb is 
also an excellent mode of administering that medicine. 
The common dose of castor oil for an infant, is from half a 
drachm to two drachms, combined with a little sugar ; a table- 
spoonful may be given to a child three or four years old. If 
the stomach should be unusually delicate, the medicine may be 
made into an emulsion, with some aromatic infusion, by the in- 
tervention of mucilage, or the yolk of an egg.t After these 
have produced their effects, the irritability of the bowels should 
be calmed with an anodyne, either the tincture of opium or 
Dover's powder. The latter preparation, otherwise known by 
the name of the compound powder of ipecacuanha, is a very 
mild and safe opiate for children, and may be given in doses 
of a quarter to half a grain during the first three months, and 
from one to three grains after a year, and from three to six 
grains at the ages of four to seven. Tincture of opium may 
be given in the following doses : half a drop for a child under 
ten days ; a drop for one from that period to the end of the month : 
a drop and a half or two drops for one from that period to three 
months ; three drops from this time to nine months ; four drops 
from nine months to eighteen ; five or six drops from that time 
to three years ; then for every succeeding year a drop or two- 
may be added. J It will seldom be necessary to repeat the laxa- 
tive medicines after the bowels have been freely moved, for it 



* fy, Magncs.. 3ss. 
Tinct. Rhei, 3j. 
Aquse Cinam., 3vi. 
Syrup. Simpl., §j. M. 
A teaspoonful every hour, to a child 
of six months, until the bowels are freely 
evacuated. 



;ss. 
Syrup. Rosae, gss. 
Vitel. Ovi, un. 
Aquae Anisi, §j. 
Dose, two or three teaspoonsful, to b» 
infant of six months. 



X Dewees, Op. Cit., p. 363. 



198 DISEASES OF CHILDREN. 

may then be reasonably supposed that the offending cause has 
been removed. If, however, the purging should continue, it will 
be an evidence of a considerably excited state of the mucous 
membrane ; and in addition to the necessary attention to the diet, 
by the use of mucilages combined with the customary food of 
the child, and its mixture with an alkali, as mentioned under the 
article indigestion, it will become the duty of the physician to 
endeavour to arrest the discharges from the bowels. Indeed, 
it has been made a question whether any attempt should be 
made to remove the feculent matters by an aperient, for fear 
of irritating the mucous membrane. E vanson and Maunsell, also, 
are of opinion, that when the infant is very young and the 
evacuations profuse, we should in all cases try to moderate the 
discharge from the bowels from the first, and only use aperients 
when the diarrhoea is recent, and occurs directly in connection 
with an overloaded state of the bowels.* This practice is 
doubtless the best, when we are satisfied that this simple diarrhoea 
depends on other causes than irritation from acid or acrid con- 
tents of the bowels. This, however, is rarely the case. Where 
it does arise from this internal irritation, the experience of the 
most eminent practitioners, both of former daysf and of the 
present, go in support of the views here advanced ; and that 
where there is an irritating cause acting on the mucous mem- 
brane, the attempt should first be made to remove it, and thus 
endeavour to allay the irritation of the mucous membrane. If 
these fail in effecting this object, opiates and other measures must 
be used to calm the commotion of the bowels. Before having 
recourse to direct astringents, it will be the better practice to 
endeavour still to remove the irritating acid matters, by neu- 
tralizing them with some fixed alkali, as potass or soda, which 
also exerts a direct sedative influence on the gastro-intestinal 
mucous membrane, thereby equalizing the inordinate peristaltic 
motion of the bowels.J Super-carbonate of soda is a very 
useful adjunct to magnesia, where much acidity prevails, and 
when large doses of the latter would act too powerfully on the 
bowels. An excellent form, also, for the administration of 



* Op. Cit., Amer. edit., p. 154. 

t The following is Harris's opinion, which was the result of much experience. 
"Diarrhoea infantum ab orgasmo humorum in imestina delabentium, Tel aturges- 
cen;ia illic bilis cum acido prcedominium habente semper profluens, nequse astrin- 
gentibus proprie diclis, nequae norcoticis est cohibenda." Harris, Op. Cit., p. 30. 
+ $ Sodae Sup. Carb , gr. x. 
Syrupi i\ uiant ii> 3ij. 
Tinci. Opii, gtts. vj. 
Aquae, §iss. 
One drachm every two hours, to an infant of twelve months, until relief be ob- 
tained. 



DIGESTIVE SYSTEM. 



199 



super-carbonate of soda to children, is that of lozenges, made 
with sugar and gum arabic, containing one twentieth of their 
weight of the alkali. 

In those cases arising from the application of cold or wet to 
the surface of the body, the indications are clearly to restore 
the lost action of the skin, which is generally found harsh and 
dry. Dover's powder, or small doses of ipecacuanha, are the 
proper medicines for effecting this object. The subjoined for- 
mula will be found peculiarly applicable to such cases,* espe- 
cially if assisted with warm bathing and fomentations. 

If the disease resists the measures already recommended, 
and there still continues evident acidity of the stomach and 
bowels, it will then be necessary to have recourse to more 
powerful measures to arrest the discharges. Chalk, or the fri- 
able carbonate of lime, is a powerful antacid, and is a very 
efficacious medicine in diarrhoea, after the irritating matters 
have been removed by aperients. f A small quantity of opium 
may be added, where the case is obstinate, and the discharges 
profuse. 

Pure argil has of late been much used in diarrhoea, accom- 
panied with acidity, as it forms with the acids an astringent 
salt. The substance is prepared from the sulphate of ammo- 
nia and alumina, by exposing it to a strong, red heat, in a cru- 
cible. Argil, in the form of a white powder, remains, possessing 
great astringent powers. It has been very freely used by the 
German physicians. Riecke recommends the formulae which 
are subjoined4 

A strict attention to the diet of the child is of the greatest 
importance in the treatment of this disease, arising from what- 
ever cause. When the nurse's milk agrees with the infant, no 
other substitute should be made for it; when otherwise, the di- 
rections, under the article indigestion, for the proper substitute, 
will be applicable to the disease now under consideration. In 
older children, the diet should be of the simplest and most unir- 
ritating kind. At first, no food should be taken ; barley or rice 



* l$c Sodae. Carb. Excic, gr. vi. 
Pulv. Ipecac, gr. j. 
" Ipecac. Com., gr. vi, 
" Sacchar. Alb., 5ij. 
Nitratis Potassae, gr. x. M. 
Divid. in pulv. vi. 
One every two or three hours, 
t fy Pulv. Acacia, 3j. 
Solve in 

Aq- Poeniculi, §j. 
Adde, 
Cretae, 5ss. 
Syrup. Simpl., §j. 
A teaspoonful every two hours. 



X fy Emuls. Sem. Papav., giijss. 

Argillae Puree, 3ij. 

Syrup. Althaea?, §ss. M. 
A teaspoonful to a child two years old, 
affected with diarrhoea. 

T$c Argil. Pur., 3ss. 
Gum-Arab., 3j. 
Sacch. Alb., 3ij. 
Aq. Fosnicul., f iij. M. 
A teaspoonful to a child a year old. 



200 DISEASES OF CHILDREN. 

water should be all that must be allowed, or, perhaps, a little 
thin arrow-root. Often, by such a course, the disease will be 
arrested in the first twenty-four or thirty-six hours ; for from 
the entire abstinence, there will be no fecal matters to keep up 
the irritation. For some days it will be necessary to keep the 
child on light, thin description of food, such as tapioca, sago, 
arrow-root, or rice. The latter article, when well boiled, affords 
an excellent diet for those predisposed to looseness of the 
bowels. 

SEROUS DIARRHCEA. 

This disease has also been described under the name of diar- 
rhoea aquosa, and by Dr. Cullen considered as a variety of 
mucous diarrhoea. It has also been known by the popular name 
of watery gripes. 

Etiology. — Serous diarrhoea may be the effect of a continued 
simple flux, the feculent variety not unfrequently terminating 
in the discharge of serous or watery stools. Any of the causes 
which produce the first variety may be considered as the cause 
of this. It is sometimes produced by the application of cold to 
the surface of the body, and in that case depends on an excited 
or inflamed state of the mucous membrane of the intestines, a 
sudden check of perspiration turning the current of the fluids to 
the bowels. In children who are old enough to use ordinary 
articles of food and drink, it will sometimes arise from a too 
free use of cold drinks or acid fruits. For the most part, how- 
ever, it appears to be connected with an opposite condition of 
the mucous membrane, which will be considered when we 
treat of the pathology of the disease. 

Semeiology; — The symptoms of the disease may be easily 
understood from its various names. The discharges consist 
mostly of serum : sometimes limpid and almost colourless, at 
other times mixed with mucus, or minute shreds, or coloured 
with bile ; but in all its forms it is characterized by copious 
watery evacuation which, at the period of teething, is often 
so abundant and debilitating, that the child is in a few days 
very much emaciated and exhausted. If, however, the dis- 
charge be moderate, the infant may not suffer much, even if it 
continues for a long time ; and in robust children a moderate 
diarrhoea, during the period of teething, appears to be salutary. 
It is more serious in proportion as it is complicated with other 
affections common during teething, such as aphthae or encepha- 
litis. When such complications exist, children very quickly 
perish. 

Morbid Anatomy axd Pathology. — Although the augment- 
ed secretion may sometimes depend on an excited condition of 



DIGESTIVE SYSTEM. 201 

the mucous membrane, bordering on inflammatory action, yet 
in general it cannot be regarded as an acute disease, but as 
one arising from an exalted condition of the exhalents, pouring 
out their contents from loss of tone. This condition exists in 
a peculiar manner in teething children ; and the muciparous 
follicles are at that period in a state of activity, which renders 
their size larger, and their number greater ; and they secrete 
a large quantity of fluid, probably to assist in the elaboration 
of the food. This explains the frequency of those serous dis- 
charges from the bowels in teething children, in whom there 
exists an increase in the functional activity of the follicles. 
M. Billard has given several dissections of children, who died 
from inordinate serous discharges from the bowels during the 
period of teething, by which the fact above stated is fully 
proved, a number of well marked uninflamed follicular plex- 
uses being discovered. It is, therefore, according to this wri- 
ter, unaccompanied by inflammation; but. in some cases a 
condition of relaxation, or a state of simple exaltation of func- 
tional power, and the diarrhoea and consequent marasmus 
which were observed in the cases cited, were owing to an 
abundant secretion from the intestinal tube. 

Treatment. — From the view of the disease here taken, the 
treatment may easily be deduced. In cases in which it is 
clearly produced by the application of cold to the external, 
dermoid surface, the indication is evidently to restore the action 
to the skin, while the discharges are at the same time con- 
trolled, if they are excessive, by some astringent drink ; com- 
mencing with the mildest. An infusion of the root of Gera- 
nium maculatum, in milk, in the proportion of half an ounce to 
a pint, is a good astringent. To an infant of six months, a tea- 
spoonful may be given five or six times a day ; a tablespoonful 
or two to children two or three years old. An infusion, also, 
of the bark of Rubus villosus, common blackberry, may also 
be used in the same manner. In moderate cases, however, 
mucilaginous substances should be freely given, as a decoction 
of linseed, or isinglass boiled in milk. Mucilage of gum aca- 
cia will completely cover the nauseous taste of ipecacuanha, 
which it will be necessary to give, to effect the object above 
stated, of restoring the action to the skin.* 

Ipecacuanha is one of the best diaphoretics which can be 



* fy Pulv. G. Acaciae, 3ij. 
" Ipecac, gr. iss. 
Aqua, I j. 
Sacchar., q. s. 
A teaspoonful every two or three hours, for a child two years old. 
26 



202 DISEASES OF CHILDREN. 

administered to children, as it does not excite any inflammation 
in the alimentary canal : and as it never causes much prostration, 
may be given to the youngest infant with safety. It may be 
added to any of the cretaceous preparations, when the dejections 
are frequent, and the necessity for stopping them appears to exist. 
Dover's powder, in this form of diarrhoea, is an admirable pre- 
paration, often of itself sufficiently controlling the excessive 
discharges, while its action on the skin tends greatly to restore 
the equilibrium of the circulation. It may be combined with 
a small quantity of calomel, if there appears to be a deficiency 
in the biliary secretion. 

If these means do not succeed in arresting the disease, astrin- 
gents, of a more powerful character than those mentioned, when 
the disease is violent, must 1 s used. Kino and catechu are 
among the most efficient, and have been much used to arrest 
inordinate action of the bowels ; and where it is so excessive 
as greatly to reduce the child, these and other astringents may 
perhaps be required. Two to four drachms of the tincture of 
catechu may be added to any of the cretaceous preparations 
already mentioned, or argil may be given, as in formulae at p. 199, 

BILIOUS DIARRHOEA. 

This form of diarrhoea, in every grade, is not an uncommon 
disease among children during the summer and autumnal 
months. It affects them at all ages, from the infant of a few 
days to the child at every period. Infants, however, are much 
more liable to this affection than children at a more advanced 
age, from the great susceptibility of the system to external 
impressions. The heat of the atmosphere being its principal 
cause, such a result might very naturally be expected. 

Etiology. — Diarrhoea, consisting chiefly of bile, is caused by 
an inordinate secretion of that fluid, possessing, without doubt, an 
unusual degree of acridness, by which the peristaltic motion is 
excessively increased. The most common remote cause is 
high atmospheric temperature acting on the liver, and greatly 
exciting its secretory functions. That a heated atmosphere 
will produce such effects in the autumnal months of temperate 
climates, and to a much greater extent in intertropical regions, 
is a fact that has been noticed by all authors. The effect of 
this agent in the production of hepatic affections, was long 
since remarked by Celsus.* It has also been observed by nu- 
merous authors of modern days, who have resided in hot cli- 
mates : Johnson, Mosely, Beddoes, Lind, and others. Indeed, the 

* Omnis calor et jecur et lienum inflamat. Lib. ij. c. i. 



DIGESTIVE SYSTEM. 203 

prevalence of this affection during the hot months, and in hot 
climates, and its almost entire absence in colder seasons and 
in higher latitudes, scarcely allow of a doubt, that it is to the 
influence of atmospheric heat that these hepatic affections are 
principally to be attributed. 

It is difficult to explain, in a satisfactory manner, how heat 
operates in exciting the hepatic secretion. It is, however, 
probable, that it is by its directly stimulating effect on the cir- 
culation — the part most freely supplied with blood being the 
part first to feel the effects of this agent, from the expansion 
of its fluids. The liver is more liberally supplied with blood 
than any other organ, as it possesses two sets of blood-vessels 
for nutrition and secretion, and on this account would the soon- 
est feel the effects of heat. 

It not unfrequently happens that bilious diarrhoea will be 
produced by improper food, and especially by bad milk of the 
nurse. Constant acidity attends it under these circumstances ; 
and its immediate cause would appear to be an irritation, and 
perhaps inflammatory action in the duodenum, transmitted to 
the liver by continuous sympathy. 

Semeiology. — The evacuations are at first feculent, and 
afterwards present the appearance of pure, healthy bile. Often, 
however, they are variously coloured, from a bright yellow to 
a deep green. The urine is often coloured of a deep yellow, 
and the eyes and skin are sometimes tinged with the same hue. 

An acid odour is frequently perceptible in the breath of a 
child affected with this disease ; the evacuations are then green, 
and from the actions of the child, and the relief usually expe- 
rienced by pressing on the abdomen, he appears to be affected 
with colic pain. Although there may be but little bile in the 
evacuations, yet, if much acid be present, they are always 
green ; all acids decomposing bile, and producing a green pre- 
cipitate. This effect of acids on the bile has been denied by 
some, but the question is put at rest by direct experiment. 
The following is one which I made, to ascertain the truth of 
the generally received opinions on this subject. 

I procured a small quantity of human bile ; it was of a brown- 
ish yellow, and of a viscid consistence, like thick gelatinous 
mucus. A portion of this was largely diluted with pure water, 
until it exhibited the yellow appearance of ordinary bile. To 
this was added a drop of muriatic acid ; the whole became im- 
mediately of a turbid green. The coloured part afterwards 
was precipitated, leaving the fluid transparent and colourless. 
The same experiment was tried with sulphuric acid, with a 
similar result; the colour, however, was not so well marked as 
that produced by muriatic acid. Acetic acid coagulated the 



204 DISEASES OF CHILDREN. 

bile, and produced a turbid yellow, inclining to green. Similar 
results followed an admixture of the inspissated bile with these 
acids. In the latter, which was exposed to the action of the 
atmosphere, in proportion to the decomposition which ensued, 
a change occurred in the colour, which passed to a blue, and 
afterwards red. In the others, which remained tightly corked in 
small phials, no alteration appeared for several weeks. 

Morbid Anatomy and Pathology. — The mucous membrane 
of the intestines is excited to secrete an increased quantity of 
its fluids by the irritating quality of the bile ; hence the copious 
and frequent discharges from the bowels. Whenever there is 
an inordinate secretion, the fluids secreted appear to be changed 
in their qualities. This is peculiarly the case with the bile, which 
in some instances is so acrid, as to excoriate the skin which it 
touches in those engaged in dissection. The pungency of the 
bile, also, has been found so great, as to cause pustules on the 
tongue and lips. It is not surprising, therefore, that violent di- 
arrhoea should follow the inordinate secretion of this fluid, when 
in a natural state it excites a discharge of intestinal fluids, as is 
proved by the great dryness of the feces when but little bile 
is secreted. When long continued, the mucous membrane 
suffers from inflammatory action ; and in these protracted cases, 
ulceration is found in the intestines, and a sanguineous engorge- 
ment of the liver. 

Treatment. — The first indication in this disease is to re- 
move the acrid and irritating matters which are evidently its 
immediate cause, by the administration of some mild purgative, 
as castor oil. When the bowels have been thus freely evacu- 
ated, the next indication is to allay the excessive irritability of 
the intestinal tube, by a few drops of laudanum or Dover's 
powder. After the pain and irritability have been allayed, 
it will then become necessary to endeavour, as a third indication, 
to control the functional disorder of the liver, by the use of 
small doses of calomel, which appears, especially when com- 
bined with ipecacuanha, to exercise a very salutary influence 
over the hepatic system. # Calomel, given in this form, is pre- 
ferable to active purging doses, which are very apt to cause 
inflammatory irritation in the mucous membrane. Calomel 
may also be very advantageously combined with Dover's pow- 
der, whenever it is deemed advisable to allay the disturbance 
of the intestinal canal with an anodyne. The use of anodynes, 

* fy Hyd. Subm., gr. ij. 
Pulv. Ipecac, gr. j. 
Sacch. Alb., q. s. M. 
Divid. in Pulv., No. yi. 
One every two hours, for a child three years old. 



DIGESTIVE SYSTEM, 205 

however, must be considered only of temporary necessity at 
this time, and should be avoided, if possible, as long as the stools 
exhibit a large quantity of bilious matter ; and absorbents and 
astringents, so beneficial in serous diarrhoea, it is very evident 
are not applicable to the form of diarrhoea now under con- 
sideration, under any circumstances. The plan of evacuating 
the bowels, by the daily administration of mild purgatives, 
should be persevered in, until the discharges assume a natural 
appearance. 

Fever not unfrequently attends bilious diarrhoea. When this 
is the case, small doses of antimony, in the form of James's pow- 
der, may be combined with calomel, in the dose of one to five 
grains, or tartarized antimony, combined with acetate of 
ammonia.* As antimony in every form is sometimes exceedingly 
prostrating to some children, ipecacuanha may be substituted, 
when there is much fever in the form already recommended. 
When, however, there is much inflammatory irritation in the 
mucous membrane of the bowels, which may be known by 
pressing on the abdomen with the hand, and by the great heat 
of the integuments of the abdomen, both antimonials and. pur- 
gatives ought to be avoided; at least the latter should be of 
the mildest kind, and mucilages ought freely to be used. Fo- 
mentations ought, under these circumstances, to be applied to 
the bowels, by means of a flannel, wrung out in warm water. 
The warm bath, also, will be peculiarly applicable when there 
exists any inflammation. 

During the whole of the disease the strictest attention should 
be paid to diet, and no food allowed but the mildest and most 
unirritating ; arrow-root, tapioca, sago, barley or rice, well 
boiled, are the most suitable kinds of food. Rice, especially, 
from the good effects in diarrhoea following its use, has been 
supposed to contain some astringent qualities ; but nothing of 
this kind has been discovered on subjecting it to analysis ; it is, 
therefore, probably owing to its bland qualities sheathing and 
protecting the mucous membrane from the effects of the irrita- 
tion of the acrid contents of the bowels. 

MIXED AND CHRONIC DIARRHCEA. 

The preceding forms of diarrhoea present the strongly 
marked differences in the disease. It is not to be expected, 
however, that the symptoms which characterize ail these varie- 

* R; Liq. Ammon. Acet., |ss. 
Vini. Antimonii, 3ss. 
Aquae Destil., §iij. 
Syrupi Simpl., §ss. M. 
A teaspoonful every two hours, to a child eight months old. 



206 DISEASES OF CHILDREN. 

ties, are in every instance to be so clearly defined, as to bear 
the peculiar mark of one form unmingled with the others. Even 
in the most distinctly marked, all that we can expect to find, is 
a predominance of one symptom, imparting to the disease a 
distinctive form, sufficiently clear to enable the careful practi- 
tioner to direct his treatment according to the pathological 
condition which the symptoms indicate. Diarrhoea often as- 
sumes different appearances at different stages ; and even at 
short intervals the evacuations will very materially alter their 
character, and exhibit unexpected changes, of a nature very 
different from those that immediately preceded them. Indeed, 
in infants, where the system is peculiarly liable to every im- 
pression, such a blending of symptoms might very naturally be 
looked for, especially when the different causes of the varieties 
of the affection we are now considering are borne in mind. 
These causes, almost in every instance, co-exist in infants ; in 
older children, less frequently. Diarrhoea, for the most part, 
affects infants during the summer season ; and if to the influ- 
ence of heat on the liver, causing an increased secretion of bile, 
be added the changes occurring in the muciparous follicles 
during the period of the appearance of the teeth, we shall have 
two causes in operation to induce diarrhoea ; and the diarrhoea, 
possessing the characteristics of bilious and serous combined, 
will ensue. If to these be added the effects of irritating asces- 
sant or undigested food, there will be superadded the usual 
symptoms of indigestion — flatulency, colic, feculent diarrhoea, 
or the evacuation of crude, unaltered aliment. How important, 
then, is it to keep in mind, that all these various forms are to be 
expected, particularly if the disease be to any degree pro- 
tracted ; and by a careful examination of the usual si^ns of the 
internal affection, be prepared to meet the change of symptoms, 
and to adapt the remedies, properly modified, to the existing 
diseased condition of the child. It will sometimes be neces- 
sary, in addition to the direct treatment, to allay febrile excite- 
ment by the ordinary means, or to remove an occasional cause 
of the excitement by scarifying the gums, where a tooth is its 
source ; to meet the evidences of inflammation of the mucous 
membrane, which may arise in the course of the disease, in 
any of its forms, or to arrest the tendency to cerebral conges- 
tion, to which young children, during the growth of the brain, 
are peculiarly liable ; and, in short, to treat the disease on the 
only rational principle, of endeavouring to ascertain the actual 
diseased condition of the patient. Sometimes, where the disease 
is kept up by a morbid irritability, it will be necessary to allay 
it by opiates, or to arrest it by astringents or tonics, when it 
depends on continued debility and a relaxed state of the mu- 



DIGESTIVE SYSTEM. 207 

cous membrane, whatever be the most prominent appearance 
of the evacuations. These varying conditions can only be as- 
certained by close attention, and by a constant application of 
the general principles of pathology to the case under consider- 
ation. When the disease has continued, it becomes chronic in 
its character, and is the form for which the physician is most 
frequently called on to prescribe. It is in its protracted state 
that it most often, assumes all the various forms of the disease, 
the nature of the evacuations differing in each individual case, 
according to the constitutional vigour, and the different exciting 
causes which may be in operation ; and often changing in the 
same individual, so as in a short time to present all shades of 
the different varieties of the disease ; and in some severe cases 
exhibiting the symptoms of dysentery, a quantity of mucus, 
sometimes streaked with blood, constituting the nature of the 
alvine discharges. But without further remark, we will pro- 
ceed to consider chronic diarrhoea, which may in reality be 
deemed a fourth form of the disease ; as it depends for its 
cause on an irritation of the mucous membrane, different from 
the others, under the systematic arrangement adopted in this 
work. 

Etiology. — From what has been already said in relation to 
the acute form of diarrhoeal affections, it will be easily perceived 
that a continuance of the causes of the irritation of the mucous 
membrane of the intestines, will ultimately excite in that deli- 
cate and sensible tissue a morbid irritability, by which the affec- 
tion is kept up, not so much from the constant application of the 
original exciting cause, as from the existence of a newly deve- 
loped action, either of extreme irritability, or of sub-acute in- 
flammation. Although there is often doubtless a continued 
application of the original cause of the disease, such as pungent 
bile, ascessant food, irritation of feces, ye + , when the disorder 
has been protracted, its existence depends more on the newly 
developed condition of the mucous membrane, than on the 
stimulating contents of the bowels. Its cause must, therefore, 
be looked for in the long continuance of the other forms of 
diarrhoea, especially if they have been either badly treated, or 
altogether neglected. 

Semeiology. — The original form of the disease gradually 
changes its character, and the predominant symptom yields to 
a new appearance in the evacuations. From being principally 
bile or serum, they now become curdy, flaky mucous, or, 
perhaps, in severe and long continued cases, purulent. The 
feculent discharges show the evidence of indigestion, and are 
often mixed up with frothy matter, resembling yeast in colour 
and consistence. As might be expected, where indigestion 



208 DISEASES OP CHILDREN. 

bears its part in the aggravation of the disease, colic pains are 
very frequent and distressing. From the same cause, also, the 
appetite is variable ; sometimes entirely gone, at other times 
craving. The thirst is very intense, cold water being eagerly 
drank by children, at all ages. The skin is hot and dry, and 
the pulse frequent and small. This heat, as the disease advances, 
is remarkably great on the abdomen ; and, while the surface of 
the body generally may at times, and at the close of the 
disease, be comparatively cool, the abdominal integuments will 
be intensely hot. This latter symptom is a very unfavourable 
one, a preternatural heat over any part being a sure indica- 
tion of disease beneath it ; and, in the one now under conside- 
ration, shows the progress and violence of the inflammation. 
This condition of the surface of the body did not escape the 
notice of Hippocrates ; # and it was a practice with some of the 
older physicians, to detect the existence of internal inflamma- 
tion by the application of wetted cloths, and the part on 
which they soonest dried covered the spot in which inflamma- 
tion existed. The abdomon is generally very tender on pres- 
sure ; the face becomes pale, and the child much emaciated ; 
and, as the disease advances to its termination, cedematous 
tumefaction appears both in the face and limbs, while the dis- 
charges from the bowels usually give evidence of the disor- 
ganization of the mucous membrane, by the presence of puru- 
lent matter. 

Protracted diarrhoea affects the system, both by the debilita- 
ting effects of the increasing peristaltic motion, as well as by 
the prostration occasioned by the great secretion from the 
appendages to the intestines, and from the intestinal mucous 
surface. The total diminution of the powers of digestion, also 
adds to the prostrating effects of the other causes. The whole 
system also sympathizes greatly with any irritation or inflam- 
mation of the intestinal tube, and a general prostration ensues ; 
which, together with the effusion above mentioned, and espe- 
cially the great tendency to cerebral effusions, render chronic 
diarrhoea in children a most serious and fatal disease. 

Morbid Anatomy and Pathology. — Autopsical examina- 
tions clearly reveal the causes of the symptoms above stated, 
and show, with what accuracy, by sufficient attention to the 
signs of the disease, the pathological condition may be ascer- 
tained during life ; for on inspecting the bowels, they are found 
in a greater or less state of inflammation. Yet there does not 
exist a disease where the fallacy of an entire dependence on 

* Et ubi in corpore calidatus aut frigiditas, isthic morbus est. Hippoc. Aph. 39, 
sect. 4. 



DIGESTIVE SYSTEM. 209 

the autopsical examinations, as an evidence of the actual state 
of disease, and consequently as our only guide in the treatment 
in all its stages, is more apparent. Diarrhoea, in its first stage, 
can scarcely be any thing more than an excessive irritation of 
the tender mucous surface of the intestines. As it advances, 
all the symptoms show that this state of irritability has become 
a permanent affection ; the next step, that it has passed to an in- 
flammatory action ; still going onward to its fatal termination, 
the symptoms manifest a disorganization and destruction of 
tissue, which, it will be presently seen, is what is found, on a 
post-mortem investigation, to be the actual state of the affected 
part, — the remains or consequences of a condition previously 
existing, but materially different in its nature from the original 
affection. Without, therefore, regarding the anatomy of the 
part as giving us the exact state during life, it is still highly 
valuable in enabling us to form a judgment of the progress of 
the affection, and thus directing us in the application of such reme- 
dies as the chain of symptoms during life, with the corrobora- 
tion revealed by fatal cases, suggest. 

This inflammation is found to exist more particularly in the 
large intestines ; but the small intestines not unfrequently parti- 
cipate in it, especially where life has been long protracted, and 
the colon exhibits evidences of disorganization. Ulceration is 
frequently met with to a considerable extent, the ulcers having 
elevated margins, surrounded with livid-coloured patches. 
Sometimes, in the place of ulcers, there are found a number of 
tubercles, forming small elevations on the mucous membrane.* 
It is not unusual, also, to find fungoid elevations on different 
parts of the mucous surface of the intestines ; these, together 
with the thickening of the mucous membrane, very materially 
diminish the calibre of the intestines. 

It is stated by Burns,f that fatal diarrhoea not unfrequently 
reveals extensive introsusceptions, not less than fifty having 
occurred in the course of the dissections by his brother. They 
occur, in all probability, from the violence of the peristaltic 
motions, and the co-existence of sudden spasm of the bowels. 
When this is the case, there is not much inflammation present. 
Indeed, this effect is most likely to occur before the continuance 
of the disease has developed the morbid irritability and inflam- 
mation, which characterize the affection when protracted. 
The existence of introsusception, it is agreed by all, is very 
obscure during life, but it may be suspected when the disease 
terminates suddenly and unexpectedly. 

* Eberle, Op. Cit., p. 244. 

t Principles and Practice of Midwifery, including the Diseases of Women and 
Children, Amer. edit. p. 734. 

27 



210 



DISEASES OF CHILDREN. 



A diseased and congested state of the liver not unfrequently 
accompanies the disease ; a condition which, during life, may be 
known by the right hypochondrium being fuller than usual, 
and when the diarrhoea is accompanied with cough. 

Treatment. — In the treatment of chronic diarrhoea, regard 
must be had to the general principles on which the disease in 
its acute form is to be treated, of course modified according to 
the necessity of each case. A close attention to the symptoms 
will be particularly necessary, in the form of disease which 
partakes of the mixed character of the other forms, while to 
them is superadded a newly developed irritability of the 
mucous membrane. Attention must, therefore, in the first place, 
be directed to the allaying of the morbid excitability of this 
membrane, as well as to the removal of the continued irritation 
from acrid secretion, rather than to attempt to arrest at once 
the a] vine evacuations, while the food is properly regulated as 
to quality and quantity. 

When the physician is first called to prescribe for diarrhoea 
in its chronic state, it may require the administration of a pur- 
gative, to remove the still irritating feculent matter which may 
not, in the first period of the disorder, have been attended to, or 
which may have accumulated from improper food. Of the 
necessity of this course, the physician must judge by the history 
of the case, and the degree of tension and fulness of the bowels. 
Castor oil will be the safest to fulfil this indication, while the 
addition of a few drops of laudanum will tend to allay the 
excessive irritability of the mucous surface of the bowels, and 
to prevent the griping effects of the purgative, and thus fulfil 
another important indication. If fecal matter or scybala 
appear in the evacuations, it will become necessary to repeat 
the purgative, guarded in the same manner. 

While these means are used to allay the morbid irritability 
of the part immediately affected, or to remove the irritating 
■cause by evacuating the bowels, it will be necessary to correct 
the biliary secretion, and relieve the congested state of the 
liver; the one, for the purpose of procuring a discharge of 
healthy bile, and the other, to relieve the accumulation of blood 
in the extreme branches of the portal vein, by which the dis- 
ease is kept up from the partial stoppage of the hepatic circu- 
lation. For this purpose, calomel, combined with opium,* or, 
what may perhaps be less irritating, a grain or two of blue 
pill ; or when the discharges are excessive, and apparently 
accompanied with acidity, the hydrargyrum cum creta.f Care 



* ~fy Hydr. Subm., gr. iij. 
Pulv. Opii , gr. i. M. 
Divid. in Pulv., No. vi. 
One of which to be given three or four 
times a day, to a child of one year. 



t # Hydr. C. Cretan, 3j. 

Pulv. Ipecac. Comp., 3ij. 

Magn. Carb., 3ss, M. 
Four to six grains, to an infant of six 
months. 



DIGESTIVE SYSTEM. 211 

should be taken that the latter preparation do not too suddenly 
check the diarrhoea ; this must be prevented by a little castor 
oil, combined as before directed. With this precaution, other 
astringent or cretaceous preparations may be used, after the 
mercurials have had their proper effects on the secretions ; the 
tranquilizing plan being kept prominently in view. Frictions, 
with the ordinary hartshorn liniment on the surface of the ab- 
domen, or a camphor plaster, will be found highly useful means 
in the treatment of obstinate diarrhoea, when there is not much 
heat on the surface of the abdomen. 

When evidences of inflammatory action appear to exist in 
the mucous membrane of the intestines, the treatment should 
then be directed to lessen the inflammation, and an antiphlogistic 
course adopted, modified according to the violence of the disease 
and the strength of the patient. Leeches ought, under these cir- 
cumstances, to be applied over the epigastrium, and the bleeding 
from the bites encouraged by the application of a large warm 
poultice of Indian meal. A poultice of this kind is preferable 
where a continued warmth is desired, and where the patient ought 
not to be disturbed by a repeated change of the applications. It 
retains heat much longer than any other kind of poultice. A little 
moistened shorts make a good, light poultice, where there is 
much pain in the bowels. During the progress of the disease, 
the great tendency to cerebral congestion and effusion in chil- 
dren affected with diarrhoea should be kept in mind, and all 
the means in our power used to prevent an occurrence almost 
necessarily fatal. The bleeding just recommended, while it is 
the most efficacious means for combating the inflammation, 
will also tend to prevent the cerebral affections. Revulsives to 
the lower extremities, by means of a stimulating bath, will also 
be a necessary adjunct to other measures adopted to prevent 
a determination to the brain. For the purpose, also, of re- 
moving an additional source of irritation, by which a febrile 
action is excited, and the hazard of local congestion increased, 
the gums should be freely divided when the teeth appear to be 
pressing on the gums. 

The disease will often continue without any very decided 
symptoms of inflammatory action, at least to such a degree as 
to appear to require direct antiphlogistic remedies ; a sub-acute 
inflammation, or an inflammatory irritation existing, keeping up 
the morbid symptoms, and wasting the strength of the child by 
the constant discharge from the bowels. Under these circum- 
stances it will be necessary to resort to astringents, cautiously 
used, or to some of the active stimulants possessing astringent 
powers, which, in the experience of some of the ablest and most 
observing physicians, appear to exert a peculiar influence on the 



212 



DISEASES OF CHILDREN. 



mucous membrane. In protracted and obstinate cases, Dr. Baillie 
used nitric acid, which, it is said, for I have no experience in its use, 
possesses a remarkable power of allaying the morbid action of the 
mucous membrane ; this he gave in conjunction with simarouba 
and opium. This combination of powerful astringents and an 
anodyne, would appear only applicable in cases of very pros- 
trating continuance of the disease, and probably in its ulcerative 
stage.*' The same remark applies, also, to the sulphate of iron, 
which has also been used in cases of excessive atony and relax- 
ation from profuse discharges. It is given in the dose of half a 
grain three or four times a day, to a child three or four years of 
age ; or from half a grain to one grain to those from four to six 
years. Nitrate of silver, also, has been used for the same pur- 
pose, and strongly recommended by Dr. Eberle,f who remarks, 
that although it is a powerfully irritating substance, yet it acts 
frequently on inflamed surfaces with a peculiarly soothing and 
alterative influence, changing the irritability of the inflamed 
mucous membrane of the bowels. Balsam of copaiba, also, is a 
highly useful remedy under the circumstances now considered ; 
it may be given as" in the subjoined formula.J In those cases 
of diarrhcea depending on the irritation of worms, the suitable 
remedies will be detailed when that subject comes under con- 
sideration. 

During the whole of the disease, the strictest attention to 
diet will be necessary, and that consisting principally of mu- 
cilaginous substances adopted, to the entire exclusion of every 
other. This alone will often effect a wonderful change in the 
disease. Well-boiled rice, tapioca, sago, for food, and infusion 
of slippery elm, or diluted gum syrup, for drink, are among 
the most powerful remedies for controlling the morbid action 
of the mucous membrane, as they leave in their digestion but 
little feces to act as an irritant. 

CHOLERA INFANTUM. 

Among all the diseases of our infant population, there is none 
more extensive in its ravages than the diseases of the bowels, 
arising in young children, during the months of July, August, 
and September. In every section of our country, the young, 
during the period of teething, suffer from these affections ; and 



* fy Infus. Simavoubse, 5jss. 

Acidi Nitrici, gtt. iv. — vi. 

Syrupi Caryophyh, 5iv. 

Tinct. Opii., gtt. vi. M. 
One or two teaspoonsful of the mix- 
ture to be given in barley water. 



t Op. Cit., p. 252. 

t 1^ Bals. Copaibae, 5ss. 

Tinct. Opii., gt. vi. 

Mucilag. g. Acaciae, §j. 
A teaspoonful three times a day. 



DIGESTIVE SYSTEM. 213 

the most fatal of these is the cholera of infants. This affection 
prevails more in the Southern and Western states. 

It has been said by some of our writers, to be peculiar to 
the United States. This, however, appears to be an error, for 
Cleghorn, in his account of the diseases of Minorca, describes 
a disease, bearing symptoms in every respect corresponding 
to those of this disease. 

Wherever, therefore, there is great atmospheric heat, com- 
bined with malaria, and especially with that engendered by 
large collections of inhabitants, as in cities, there the disease 
is found. It is on this account extensively prevalent in our 
country ; but is not dependent on heat alone, as it is observed 
that in some of our most southern sections of country it is not 
so rife as in New- York or Philadelphia. The open country is 
remarkably exempted from this scourge. 

It prevails mostly in cities, and is in some places a remark- 
ably fatal disease. In Philadelphia it is much more fatal than 
in New- York or Boston ; and in the latter city it has been 
doubted by some whether the disease exists in its genuine 
form. 

The great mortality of cholera infantum, and the extreme 
range of the disease, make it one of the most interesting to the 
physicians in this country. It has accordingly from time to time 
received the attention of physicians, as appears from the num- 
ber of essays which have been published. Among these is the 
excellent practical one of Dr. Rush, first published in 1789 ; 
that of the late Dr. Millar, of New- York, in the year 1800, and 
the Boylstonian prize essay of Dr. James Mann, on the cure of 
the autumnal diseases of infancy, as prevailing in New-England, 
published in 1 805. Dr. Jackson has also recorded some excellent 
observations on the disease, in the first volume of the New-Eng- 
land Journal of Medicine and Surgery. Drs. Dewees and Eberle, 
also, have given some valuable remarks, the result of much 
experience in the disease, in their respective treatises on the 
diseases of children. Dr. Horner's essay, published in the third 
volume of the American Journal of the Medical Sciences, is 
the only complete and satisfactory account we possess of the 
morbid condition of the parts immediately connected with the 
most prominent symptoms, and is a valuable addition to our 
stock of knowledge, by which some approach may be made to 
the formation of a correct theory of the disease. Other essays 
will be referred to in the course of these remarks. 

Etiology. — The consideration of the causes of cholera infan- 
tum is probably of more importance in its management than 
perhaps that of any other disease of infancy. The constant 
recurrence of the disease in every warm season, in almost every 



214 DISEASES OF CHILDREN. 

part of our country, has rendered us familiar with the symp- 
toms, and, although the contrary would appear to be the fact 
from the great and uncontrollable mortality, also with the most 
efficient mode of treatment. It is, therefore, to the predisposing 
and the constant operation of the exciting causes, that we must 
chiefly look for the continued fatal progress of the disease. 

The consideration, therefore, of its causes, becomes of the 
greatest importance in its treatment; and in vain will the re- 
medies be applied for its removal, while the causes of its 
existence are still in active operation, and more active in pro- 
portion to the loss of vigour, and the increased inability of the 
child to resist them. 

The two principal predisposing causes are teething and im- 
proper food. The action of teething, or rather the condition 
of the system connected with the developement of the teeth, is 
one of increased excitement, from the universal sympathy of 
the different parts of the body with the irritation existing in the 
gums. The eruption of the teeth is also connected with very im- 
portant changes throughout the mucous surface of the digestive 
tube. It is a remarkable fact, and one which has been noticed 
by all writers on the disease, that the time of teething is a 
period at which cholera infantum appears, and that this con- 
dition of the system is essential, in union with other causes, to 
its formation ; the exceptions which occur go rather to the 
establishment of the fact, as they are in close connection with 
the changes in the digestive tube, on which the developement 
of the disease depends. 

Another predisposing cause is error in diet. It is unneces- 
sary here to enlarge on the subject of inappropriate food for 
young children as a cause of disease. It is sufficient to refer 
to it as an unnatural stimulant, which, by its irritation, either 
excites the organs of assimilation to a preternatural and exces- 
sive action, — a state which it will hereafter be seen is essentially 
connected with the disease in question, — or it maintains them in 
the condition of excitement, after the usual period of these 
changes, which occur at the time of the eruption of the first teeth. 

Long continued heat is the ordinary cause of cholera infan- 
tum ; and it invariably makes its appearance after the hot 
weather of our summer season has commenced, and prevails 
generally in proportion to the degree of heat ; consequently it is 
no uncommon thing to find some seasons almost exempt from this 
scourge, when the range of the thermometer is comparatively 
low. As it appears with the hot weather, so does it disappear 
on the arrival of the cold, at the commencement of autumn. 
This is so invariably the case, that heat must be regarded as its 
principal cause. Although heat is one of the chief agents in 



DIGESTIVE SYSTEM. 215 

the formation of the disease, yet, from its almost entire absence 
in the open country, where the range of thermometer is often as 
high as in cities, it is evident that other causes must exist, in 
connection with heat, to produce the disease. This is found in 
the malaria, principally of cities. In the densely populated 
parts of our cities, amidst the impurities engendered by poverty, 
the disease prevails during the heat of our tropical summers 
with great mortality. In the thickly populated portions of 
large towns and cities, it appears principally to spend its 
force ; while in other parts it is comparatively rare. A 
close, dense, impure, and heated atmosphere, connected with 
the predisposition produced by teething, are therefore the 
causes of cholera infantum. All these conditions appear to be 
necessary to its developement, as no one of them alone has 
been found sufficient to produce the disease. It is not found in 
teething children in the salubrious air of the country ; nor does 
it prevail at any other time than during the period of dentition ; 
and among these only at particular seasons of the year. It is 
stated, that it occurs before the period of teething ; but when 
this is the case, there exist other causes, having a connection 
with the pathology of the disease, and developing the same 
condition of the system, which is present during the active state 
of dentition. 

Semeiology. — Cholera infantum is very variable in its ap- 
proach ; scarcely any other symptom, however, exists at first than 
diarrhoea, often continuing for several days without any nausea 
or fever. Although, for the most part, this is the first symptom 
on the invasion of the disease, yet it not unfrequently happens 
that vomiting accompanies the purging from the commence- 
ment of the disease. When the latter symptom exists at first, 
in connection with the diarrhoea, the disease is proportionally 
severe ; for under an attack so violent the disease usually termi- 
nates fatally in a few days. For the most part, however, the 
diarrhoea will commence with the discharge of ordinary fecal 
matter, which very soon, however, changes to a thin, serous 
looking fluid, variously coloured. When the disease is fully 
formed, the ordinary feces are retained, and the evacuations 
are mostly of this watery fluid, coloured brown white, some- 
times yellow and green. They are at times very offensive, and 
again without any other odour than what arises from acidity. 
In the greatest number of instances they are offensive, but not 
of the peculiar character which distinguishes fecal matter ; it 
appears to be of the nature which characterizes the ordinary 
decomposition of animal matters. According to the location 
of the disease in different parts of the intestinal tube, the evacua- 
tions present a difference in their consistency and appearance ; 



216 DISEASES OF CHILDREN. 

thus, when the lower portion of the intestines is affected, the dis- 
ease bears a resemblance to dysentery, and the evacuations are 
slimy, gelatinous, and bloody ; while tenesmus and pain, on 
evacuating the contents of the bowels, are very severe. In 
the most severe cases, the evacuations show the extent of the 
disease throughout the entire intestinal tract ; and it is in such 
cases that they present a great difference in their appearance, 
including all the above varieties, and at times mixed with a 
frothy matter resembling yeast, and with imperfectly digested 
food, or that which has passed almost unaltered. 

The diarrhoea, after it has continued for a few days, is fol- 
lowed by an obstinate vomiting, or attempts to vomit ; one of 
the most distressing and uncontrollable symptoms of the disease ; 
preventing the administration of medicine, and even the swal- 
lowing of drinks, which are eagerly demanded by the little 
patient. 

Fever, of a very irregular character, occurs at an indefinite 
period of the disease, and is remarkable for its irregularity. A 
very unequal heat exists in different parts of the body. The skin 
is cold and pale, with the exception of that part covering the 
abdomen, which, together with the head, is excessively hot, 
showing a great determination of blood to these parts. From 
the actions of the child, he appears to suffer from severe pain 
in the head. Pain, to a greater or less extent, is experienced on 
pressing the abdomen. This pain and heat increase with the 
progress of the disease. 

The pulse is small and wiry, and its frequency denotes a 
great degree of irritability, and is by no means indicative of 
much general disturbance. The local affections above men- 
tioned are the most marked derangements which exist in the 
circulatory system. That of the brain is a very prominent one ; 
and in addition to the heat and turgescence of the head, the 
eyes exhibit this state by their suffused and bloody condition. 
At times they appear as if really inflamed ; when this is ob- 
served, there is great restlessness and delirium. On the other 
hand, there may exist great stupor and insensibility to every 
impression, when the eyes are dull and inexpressive ; the child 
sleeps much, with the eyes partially closed. 

The tongue is for the most part dry, a little furred, of a bright 
ash colour ; or it may be without fur, but red and dry. This 
latter state occurs more especially as the disease advances, 
and the stomach becomes the seat of the greatest part of the 
disease. 

The skin, which at first is generally pale and clammy, be- 
comes, as the disease advances, dry and ash coloured. It 
hangs loose, and in folds about the body, while over the fore- 



DIGESTIVE SYSTEM. 217 

head it is drawn tight. The cheeks become shrunken, and as 
the disease advances to a close, the bony prominences of the 
face, and the shrivelled aspect of the cheeks and lips, give to 
the infant the expression and appearance of an old person. 
The muscles, in every part of the body and limbs, are shrunk 
and flabby. 

The emaciation is very rapid in this disease, there being no 
digestion of food, while a discharge of the fluids is taking place 
with scarcely any intermission. 

Dr. Dewees mentions the existence of a number of minute 
vesicles, of a crystalline appearance, on the chest, and con- 
siders it a very unfavourable symptom. I have never been 
able to discover it ; and indeed, he observes, that it may readily 
escape observation.*' 

The disease is usually protracted to two or three weeks, and 
sometimes, even to some months ; its average duration is about 
three weeks. 

The prognosis of cholera infantum is a subject of great un- 
certainty, from its liability to sudden changes, even after the 
establishment of favourable symptoms. When, therefore, the 
disease proceeds onwards, without any mitigation of symptoms, 
its fatal termination may be expected with scarcely any doubt. 

The first appearances in the amendment of the child, are in 
the abatement of the febrile symptoms, and the ability to retain 
drinks or medicine. The stools, also, change to a more natural 
hue, while the odour is more like that of the natural feces. 
The presence of bile in the discharges is almost always a certain 
evidence of recovery, as its absence is an unequivocal sign of a 
fatal progress of the disease. While these symptoms appear, 
the pulse at the same time is slower and more full, the heat 
leaves the head and abdomen, and becomes more diffused over 
the surface of the body. 

Morbid Anatomy and Pathology. — Dissections of those 
that have died of cholera infantum, show that the abnormal 
alterations are principally confined to the abdominal viscera. 
The brain especially, in some protracted cases, is in a state of 
congestion, with serum effused in the ventricles ; a condition 
usually occurring in all protracted cases of disease in children, 
and therefore is not to be regarded as peculiar to this. The 
thoracic viscera are always in a healthy condition. 

It is a remarkble fact, that all who have recorded dissections 
of those who have died of cholera infantum, speak especially of 
the liver, as being greatly enlarged, and in a state of complete 
sanguineous engorgement; and not only enlarged, but of a 

* Op. Cit., p. 398. 
28 



218 DISEASES OF CHILDREN. 

firmer texture than natural. According to the various state- 
ments recorded, it has been found so large as to occupy two 
fifths,* one half,f and even two thirds, of the abdominal 
cavity.J The intestines, also, exhibit the effects of inflamma- 
tion m every portion of their track; but especially in the mu- 
cous coat of the duodenum, jejunum, and lieon. Dr. Hcrner 
has satisfactorily proved, that the morbid alteration exists par- 
ticularly in the mucous follicles of all the intestines ; and so 
marked were the cases dissected by him, of follicular inflam- 
mation, that he compared the appearance to the vesicular dis- 
eases of the skin. This, therefore, with the enlarged state of 
the liver, constitutes the essential characteristics of the morbid 
anatomy of cholera infantum. 

It is a remarkable fact in the history of this disease, that 
three circumstances are necessary to its production. The 
state of the system occurring during dentition, a high atmos- 
pheric temperature, and an impure state of the air : no one of 
these alone is in general sufficient to form it ; nor do any two of 
them appear to be the agents of its formation. It never ap- 
pears in the pure air of the country ; nor does it prevail in 
cities at any other season than the summer ; nor does it attack 
children, except during the period of dentition ; scarcely ever 
occurring after the teeth have all appeared. To this last rule 
there have been a few exceptions ; and the disease is then 
always attributable to some error in diet, by which the deve- 
lopement of the follicular apparatus takes place prematurely, 
placing the child in the same pathological condition as that 
which occurs during the time of dentition, from a natural, 
though at times an excessive developement of the mucous fol- 
licles of the intestines ; a state which we have already seen to 
be the morbid condition of the bowels in this disease. 

It is a very striking coincidence, that M. Billard, in his valu- 
able essay on the pathology of infants, has shown that the fol- 
licular apparatus of the intestines is in a state of active deve- 
lopement, simultaneously with the appearance of the teeth ; and 
that every part of the digestive system undergoes at this period 
a change in its functional action. In connection with this state 
of the part, the congested state of the liver, produced by the 
heat of the weather, particularly when aided by an impure 
state of the air, becomes the principal source of the disease, 
by preventing the return of blood from the intestines through 



* Dewees, Op. Cit., p. 400. Jackson, in N. E. Journ. of Med , vol. i. p. 24. 
t Remarks on Cholera Infantum, by Harvey Lindsley, M. D., Amer. Journal 
of Med. Scien., vol. xxiv. p. 305. 
t Horner's Path. Anat., p. 171. 



DIGESTIVE SYSTEM. 219 

its ordinary channel. The mucous follicles, already predis- 
posed to disease by their natural developement above men- 
tioned, are excited to morbid action, by being thus crowded 
with an undue amount of fluids.* 

Treatment. — From the view here taken of the disease, it 
is evident that our chief efforts should be directed, in the first 
place, to the removal, if possible, of those exciting causes on 
which the disease depends for its continued existence. It has 
been ascertained that heat and a vitiated atmosphere are the 
chief exciting causes ; and it will be but of little avail if the 
therapeutic measures are used, while the child is continually 
exposed to the ordinary agents producing the disease. This 
is seen in other diseases ; and convulsions have prevailed in 
hospitals, which resisted the treatment usually pursued in such 
cases, until the impurity of the air breathed by the children 
began to be suspected as the principal cause ; when this was 
remedied, the convulsions, before so fatal, became comparatively 
a rare and mild disease. 

It will therefore be necessary, in every instance, to be scru- 
pulously particular in the direction of every thing that can 
correct the extreme heat and purify the air. Among some 
exposed to the sufferings and privations of poverty, this may 
be a difficult, if not an almost impossible undertaking. Some- 
thing, however, may be attempted by daily exposing the child to 
the reviving influences of the fresh air, by a walk in the cool of 
the day in the vicinity of the water ; by frequent ablutions 
with cool water when the weather is excessively hot, and by 
the adaptation of the clothing to the existing temperature. 
These are important measures, both in the prevention and cure 
of cholera infantum ; but more especially are they applicable 
to all children in the heat of summer, w T hereby this formidable 
disease may be prevented. The causes are clearly ascertained, 
and it is the duty of every physician to exercise all his influence 
in the prevention of this fatal scourge. 

Even among those whose circumstances have placed them 
above the effects of poverty, an inattention to the ordinary 
rules of hygiene is often apparent ; and from crowding too 
many children in one room and one bed, and carefully exclu- 
ding the air, expose them to all the bad effects of heat and a 
contaminated atmosphere. Often before the appearance of 
this or its kindred diseases, children may be seen to suffer from 
the effects of heat and stagnant air, languid and sweltering 
from the accumulated heat of the night. 



* For a more detailed account of the pathology of Cholera Infantum, see Ap- 
pendix to Billard, p. 580, et seq. 



220 DISEASES OF CHILDREN. 

How easy, then,'is it for those whose situation in life enables 
them to adopt the proper measures to counteract the effects of 
excessive heat, to use these simple prophylactic measures. The 
doors of all the bed-rooms should be thrown wide open ; and 
no danger need be apprehended from leaving the upper sash 
of a bed-room window a little open at night, to allow of a free 
passage of air, while the bed is so removed as not to be affected 
by the current. 

During the extreme heat of the summer, especially, should 
all feather beds, and every species of bed-clothes calculated to 
retain heat, be removed, and a hard mattress be substituted, while 
the body is lightly covered. In the daytime, a still freer circu- 
lation of air should be encouraged, by keeping opposite win- 
dows open. Every opportunity, also, should be embraced in 
fine weather, for procuring the advantage of a change of air, 
by means of the numerous advantages now afforded for expe- 
ditious aquatic jaunts. 

One of the most important measures which has been recom- 
mended by all experienced practitioners, and the good effects 
of which I have in many instances seen, is the administration 
of cold water to children. The activity of the nutritive pro- 
cess is very great in all young animals ; and in proportion to 
the activity of the capillary circulation, is the demand for a 
supply of fluid, lost in building up the frame; in addition to 
this, the cutaneous transpiration, during high atmospheric heat, 
increases the demand for fluid. All persons who have had any 
experience in the wants of young children, know how frequent 
is the demand for drink, especially at night. Sucking infants 
experience the same distressing want, but are unable to express 
it in language always to be understood. Extreme restlessness 
and fretfulness may often be calmed by a draught of cool wa- 
ter ; and the allaying of simple uneasiness in infants, is itself 
a most important measure for the prevention of disease, where 
the nervous system is so susceptible to impressions as at this 
tender age. Besides these measures, it is obvious, from the 
preceding remarks, that too much care cannot be bestowed on 
the food that the child takes, undigested nourishment being a 
continued source of irritation to the tender mucous membrane. 

All these preventing measures are also applicable to the dis- 
ease, subject, of course, to such modifications as the nature of 
the existing symptoms will suggest to the medical attendant.*' 

In the forming stage of the disease, from the view here taken 



* For full remarks on the Prophylactic Treatment of Cholera Infantum, see a 
paper by the late Dr. Parrish, in the second volume of the N. A. Med. and Surg, 
journal. 



DIGESTIVE SYSTEM. 221 

of the agency of the liver in the formation of the disease, it is 
evident that the first step in the treatment would be to abstract 
blood, perhaps by means of leeches. This, however, is rarely 
the course which can be adopted, from the disease having 
already made considerable progress before the physician is 
called to prescribe, and the effects of the congested state of the 
liver having already appeared. 

It is the custom of some practitioners to give emetics at the 
commencement of the disease, to remove actid and irritating 
ingesta : this practice, however, cannot be too highly reproba- 
ted. It is seldom that the immediate cause of the disease 
in question can be traced to the presence of any indigestible 
matters in the stomach, which requires removal ; for, in by far 
the greatest number of instances, the appetite has been for 
some time impaired, before the disease is fully formed. The 
great irritability of the stomach during the progress of the dis- 
ease, and the necessity and difficulty of controlling its morbid 
activity, render it extremely hazardous to adopt any measures 
which might produce one of the most unmanageable symptoms 
of the disease. 

These remarks do not apply, however, to the removal of 
irritating feculent matter contained in the bowels, and which 
is usually in a state of putrefaction and fermentation, adding 
thereby greatly to the existing irritation ; any of the mild 
cathartics already mentioned, but especially the sulphate of 
potash, may be used for that purpose. But as one of the in- 
dications in the cure of this disease is to excite the liver into 
action, and thus relieve its congested state by a free secretion 
of bile, the use of calomel will be found the most efficacious, 
both in evacuating the bowels, and restoring the healthy action 
to the liver. All our efforts will be useless until this organ is 
brought to its normal state, and our other measures will be 
without avail, unless its full activity is restored. When this is 
accomplished, the free circulation of blood from the intestines 
is secured, and the turgid and congested state of the remote 
branches of the portal vein relieved. 

This important step in the treatment should therefore re- 
ceive our earliest attention ; we should, on this account, as the 
most effective means both of removing the irritating contents 
of the bowels, and restoring the action of the liver and to the 
whole glandular system, resort to mercurial remedies. 

The use of calomel in the treatment of cholera infantum, 
was first recommended by the late distinguished Dr. Edward 
Miller, of New- York, in the New- York Medical Repository, for 
the year 1800. The advantages arising from its use have 



222 DISEASES OF CHILDREN. 

been appreciated by all practitioners since his time, and it con- 
stitutes the basis of the treatment of the disease in every part 
of our country. 

Dr. Miller was in the habit of using it according to the pe- 
culiar circumstances of the case, and observes, that it is difficult 
to determine the question with precision as to the proper dose, 
for it should be accommodated to the age, constitution and 
habits of the child, and to the different stages of the complaint. 
As a general ru\&, he gave to a child of two years, a pill, com- 
posed of one sixth of a grain of opium and a third of a grain of 
calomel every second, fourth or sixth hour. The proportions 
of calomel and opium to be varied according to the necessity 
of astringing or opening the bowels. 

This method, and that recommended by Dr. Dewees, of 
giving small doses of calomel uncombined, I have found useful ; 
and these are suitable to different conditions of the system. 
The latter is more useful in the first stage of the disease, 
before it becomes necessary to attempt the control of the 
excessive and debilitating serous discharges, and when the 
calomel appears to pass off without any influence on the liver. 

The use of calomel should be continued until a manifest 
alteration has taken place in the stools, and a free secretion of 
bile is evident from their appearance. This is the main object 
to be attained ; for a general change in the system immediately 
ensues, on the restoration of the hepatic action. 

Calomel, in every instance, had better be given in a small 
quantity of simple syrup, whereby it is in general more easily 
swallowed than if given dry. The quantity of the medium in 
which it is given ought to be very small ; any disordered action 
of the stomach will thereby be prevented ; for every preventive 
measure ought to be adopted, to anticipate, if possible, the 
occurrence of vomiting — a symptom exceedingly difficult to 
control when once established. 

In cases where much fever attends, besides the local abstrac- 
tion of blood, small doses of ipecacuanha has been at times 
found useful, from its diaphoretic action. Although highly be- 
neficial under such circumstances, its emetic qualities will ren- 
der its employment occasionally hazardous ; much judgment 
will, therefore, be necessary in deciding on its employment. It 
ought neither be rejected altogether, nor should too much reli- 
ance be placed on its use. It should never be employed in such 
a manner as to take the place, under any circumstances what- 
ever, of calomel, at the commencement of the disease. Where 
much febrile action prevails, they may be judiciously combined ; 
and if vomiting ensue, Dover's powder may be substituted for 
ipecacuanha. 



DIGESTIVE SYSTEM. 223 

The inflammation of the mucous membrane is also allayed 
by the employment, of mucilages. The use of these in some 
measure supplies the loss of the natural mucus, which, as in 
dysentery, is continually thrown off; for although the increased 
action of the blood-vessels causes an increased quantity of 
mucus to be secreted, yet the preternatural action of the intes- 
tines causes a larger quantity to be passed off from the bowels. 
Decoctions of linseed, slippery-elm, gum-syrup, therefore, should 
form part of the general treatment, with other more active 
agents. These are more particularly called for, when tormina 
and tenesmus are the urgent symptoms of the disease. They 
may be given both by the mouth and in enemata, as recom- 
mended in dysentery. 

The warm bath is among the general remedies of unques- 
tionable value, more especially applicable at the commencement 
of the disease, before much prostration has occurred. The 
effects of warm water, thus applied to the entire surface of the 
body, produces a dilatation of the cutaneous exhalents ; an ac- 
celeration of the circulation ensues, while the cuticle is softened, 
and a diaphoresis, almost of necessity, will follow its use. 

Such are the general measures the best adapted to the cure 
of cholera infantum, and are those which we should adopt in 
the onset of the disease, and which, with occasional modifica- 
tions, ought to be used throughout its course. There is scarcely 
a case, however, in which some considerable alteration is not 
required in the management, from the persistence of some vio- 
lent symptom, which itself may very materially interfere with 
the proper use of the appropriate remedies, or become an agent 
of severe and protracted irritation, and which it will be neces- 
sary to counteract with some particular means adapted to the 
nature of the existing symptom. 

Vomiting is one of the most obstinate symptoms of the dis- 
ease, and while it continues incessantly tormenting the child, 
the administration of the proper remedies for the relief of the 
constitutional symptoms is of little avail. It must be, for a time 
at least, arrested, before the appropriate remedies can be intro- 
duced into the system ; it will, therefore, claim no little share 
of the physician's attention. 

Among the most useful anti-emetics, is lime-water, which 
should be combined with an equal quantity of fresh milk, to re- 
move the excess of its pungent qualities. This should be given 
by the teaspoonful, every half hour ; at the same time, toast- 
water ought to be given as a common drink. The quantity 
must be very small, otherwise the fluid will increase the vomit- 
ing : it should be barely sufficient to moisten the mouth. 

Dr. Dewees particularly recommends strong coffee, without 



224 DISEASES OP CHILDREN. 

either milk or sugar, as an anti-emetic ; this I have found at 
times to succeed, when other means have failed, while at. other 
times it has apparently aggravated the vomiting. The obsti- 
nate nature of the vomiting will often require the trial of almost 
every remedy which has been suggested for its relief. A drop 
of laudanum will sometimes control this symptom. A transfer 
of irritation to the lower intestines is also an important measure 
of relief, for it does not exist to so violent an extent when there 
exists much tenesmus and secretion from the large intestines. 
The injection recommended by Dr. Dewees, is very useful for 
this purpose, consisting of two or three teaspoonsful of salt, dis- 
solved in a gill of warm water. Should there be much febrile 
action accompanying the vomiting, a leech or two applied over 
the region of the stomach may be required to remove the local 
inflammation ; where this does not exist, counter-irritation, by 
means of sinapisms or other stimulant applications, or a blister, 
will at times be found useful. Among other remedies for arrest- 
ing inordinate vomiting is the spirits of turpentine, as recom- 
mended by Dr. Condie, in doses of ten to thirty drops, three or 
four times a day. 

Instead of vomiting, tenesmus is occasionally the most dis- 
tressing symptom of the disease ; this should be allayed by the 
use of opiate injections, for the continued existence of this 
symptom is exceedingly wearing to a young infant, as is evi- 
dent from the great exhaustion which often follows a paroxysm. 
Before recourse being had to opiates, the effect of simple mu- 
cilaginous injections should be tried, as the presence of indu- 
rated fecal matter may be the principal cause of this symptom. 
The directions given for the treatment of dysentery are appli- 
cable to the state of the bowels in the present disease, which 
produces this symptom. 

During the prevalence of the disease, although free serous 
evacuations may continue, the ordinary feces are apt to be re- 
tained ; this may be suspected to be the case when the abdo- 
men becomes tumid, and the alvine discharges have undergone 
no alteration. If the calomel has failed to procure an evacua- 
tion of feces, a laxative, composed of magnesia and rhubarb, 
formulas for which will be found in the article on diarrhoea, 
will be proper, to remove the acrid and highly irritating contents 
of the bowels. There is often acid existing in the stomach and 
bowels in this disease, for, from the absence of bile, no neutrali- 
zation takes place ; and dissections of those who have died, 
exhibit the presence of a frothy, acid matter, in different parts 
of the bowels ; the combination, therefore, of some alkaline or 
absorbent remedy, will most likely be called for from this pro- 
bable condition of the system. When there is no fever present, 



DIGESTIVE SYSTEM. 225 

aromatic syrup of rhubarb, with magnesia, will be found a use- 
ful prescription.* The object being simply to relieve the bowels 
of the load of irritating feces, such measures are indicated which 
will at the same time tend to produce an astringent effect on 
the exhalent vessels of the mucous membrane of the bowels. 

The opposite condition of the bowels more frequently exists 
than the one just described, the active peristaltic motion 
rapidly passing off every thing contained in them, while the 
excessive discharge of serous fluids suddenly and fatally pros- 
trates the child. The physician, therefore, is more frequently 
called upon to control this flow, which may be judiciously done, 
without interference with the general measures which it is ne- 
cessary to adopt, to remove the chief pathological condition 
on which the disease depends. 

Opium, at the commencement of the disease, should never 
be used, except under the circumstances already mentioned, 
when speaking of its union with calomel. As to the adminis- 
tration of laudanum at once, for the purpose of arresting the 
discharge, nothing can be more pernicious. 

The precautions in the use of astringents have already been 
mentioned, when treating of diarrhoea in general ; and the pre- 
sent disease may be regarded as an aggravated form of the 
serous diarrhoea attendant on teething, with the complication of 
a congested and enlarged liver, from causes already mentioned. 
A great deal of caution therefore is required, to adapt the 
remedies to the actual situation of the patient, neither rejecting 
nor using too indiscriminately such measures as will at once 
arrest the most prominent and wasting symptom of the disease. 

Although, in general, astringent remedies should be avoided 
until the free secretion of bile is established, yet, when the dis- 
ease is protracted, and the child rapidly sinking from the 
excessive exhaustion produced by the large serous evacuations, 
it will be advisable to have recourse to some of the astringents 
already mentioned. 

Dr. Mann is the first who recommended the acetate of lead 
as one of the most efficient astringents in the treatment of 
cholera infantum. Guarded . with opium, there appears to be 
but little hazard in its use. Strongly prejudiced against the 
internal use of lead, I have not given it the trial which the 



* Ifc Magnesia?, gr. xv. 

Syrup. Rhei, Aromat., 3iss. 
Spts. Nit. Dulc, 5j. 
Sacchar. Alb., 3j. 
Pulv. g. Acacise, 3ij. 
Aquae, gij. M. 
A teaspoonful every two hours. 
29 



226 DISEASES OF CHILDREN. 

experience of others should have led me to do. But in those 
cases in which I have used it, although disappointed in its 
effects, the anticipated evils never appeared. 

From the experience of others, however, it is one of the 
most efficacious astringents ; and Dr. Lindsley, of Washington, 
D. C, remarks, that there is not a more efficient remedy in the 
whole materia medica than sugar of lead and Dover's powder, 
in doses carefully proportioned to the age and condition of 
the patient;* it acts far more kindly than either kino or cate- 
chu. His prescription is subjoined.-)- Various other astringent 
remedies may be tried, as already recommended ; for at this 
stage of the disease it bears much the characters of chronic 
diarrhoea, which attends a simple exaltation of the action of 
the muciparous follicles without inflammation, where astringents 
are clearly indicated. 

As a part of the general treatment of this and of all the 
other diseases of infancy, the gums should be carefully inspected, 
and where they are found swollen from the pressure of a tooth, 
they must be divided ; not that the pressure of the tooth 
can itself be a cause of this disease, but the irritation it produ- 
ces in the system is a great source of aggravation to all the 
symptoms; and where there is so much tendency to a flow of 
blood to the head in all abdominal affections in children, the 
local irritation of the tooth should be removed, as the tendency 
to cerebral turgescence is thereby prevented. 

The disease is often exceedingly protracted ; and .even after 
an apparent removal of the symptoms, a slight error in diet, or 
a little change in the temperature of the atmosphere, will cause 
a return of the symptoms, even after some weeks have elapsed ; 
the disease for the most part being a serous diarrhoea, and in 
part arising from a morbidly relaxed condition of the serous 
exhalent vessels, while the continued action of the exciting 
causes still keeps the liver in a congested condition. Mild bit- 
ters, therefore, and gentle tonics, are indicated during the inter- 
val of relief. Infusions of Columbo root, weak infusion of ginger, 
will be found highly useful in imparting tone to the relaxed 
state of the intestines ; while stimulating diet will be needed for 
the same purpose. The instinctive desire of the child for salt 
and other stimulating articles of food, may in moderation be 



* Remarks on Cholera Infantum, by Harvey Lindsley, M. D.; Amer. Jour. 
Med. Scien., vol. xxiv. p. 311. 

t Jfc Plumbi Sup. Acet., gr. iv. 
Pulv. Doveri, gr. j. M. 
ft. Pulv., No. xij. 
One every hour, or every second hour, according to the urgency of the symptoms 
and effect of the medicine, for a child of eighteen months. 



DIGESTIVE SYSTEM. 227 

safely gratified. In cases which are evidently kept up by de- 
bility, more powerful tonics may be used ; and the sulphate of 
quinine, in minute doses, has been given with great benefit. 
Iron is also a useful tonic in such cases. The following pre- 
scription of Dr. Chapman is an excellent formula for its admi- 
nistration.* 

It is certainly a very remarkable symptom of convalescence 
in this disease, that there is so strong a desire for salted meat 
and fish ; and a piece of fat salted pork is greedily seized, and 
relished by the child, when all other kinds of food are rejected. 
Drs. Rush, Parrish, Hosack, and other distinguished physicians, 
have remarked, that children may be indulged in this instinct 
with obvious relief to all the symptoms. The juice of shell- 
fish, also, may be used with advantage during convalescence. 

This eager desire for stimulating food, affords a striking illus- 
tration of the pathology of the disease, and of the inordinate 
and diseased developement of the parts that are at this time of 
life undergoing a change, for the reception of a new kind of 
food. 

During convalescence, especially, if the child's appetite should 
have been good, on the appearance of a return of the diarrhoea, 
a dose of castor oil should be given, or a little syrup of rhu- 
barb ; the latter may be combined with magnesia, if acidity 
appear to be present. And in general, the ordinary measures 
already recommended ought to be pursued ; but modified to 
suit the case of the child, in the debilitated condition following 
a protracted disease. 

HEPATIC AFFECTIONS. 

Diseased action of the liver, unconnected with excess of 
biliary secretion, is not of unfrequent occurrence among chil- 
dren, especially during the summer and autumn. A congested 
state of this organ always precedes some forms of intestinal 
disease ; a subject which has already been considered. A de- 
ranged action, however, in the circulation of the liver, and an 
enlargement of its substance, may occur, without manifesting 
its presence in the increase of its secretion, or in the produc- 
tion of derangements of other portions of the abdominal vis- 
cera. These affections seldom, if ever, appear in the form of 
inflammation, and if ultimately fatal, become so by producing 

* fy Sal. Mortis., gr. ij. 
Acid Sulph., gt. x. 
Sacchar. Alb., 3j. 
Aq. Tom., ij. M. 
Jj. p. r. u. 



228 DISEASES OP CHILDREN. 

other diseases. We are, therefore, left without any autopsical 
examinations to guide us as to the exact condition of the liver, 
in a disease which is not frequent in some districts of country. 
I have sometimes detected the existence of arrested circula- 
tion of the liver, and by the early application of suitable reme- 
dies, have removed the morbid condition, which at other times 
appeared to be directly connected with the formation of other 
and fatal affections of the bowels. 

Etiology. — Hepatic congestion forms the most common 
complications of abdominal disease in the United States, and par- 
ticularly in newly settled districts of country, and is especially 
dependent on the malaria which abounds in such places. The 
extreme heat of the summer is also another cause, and it is at 
this season that diseases of the liver prevail in cities, and other 
situations not exposed to the malaria of marshes. Improper 
food is also another cause, particularly in children about the 
age of two years, who have been kept exclusively fed on fari- 
naceous articles of diet. Although many have thrived under 
such a course of diet, yet there are some who at this age require 
a decided change of food, and that composed partly of animal 
substances cannot be withheld without injury. 

Semeiology. — Its approach is very insidious, and at first 
exhibits no other sign than listlessness, slight fever, loss of ap- 
petite, and a furred tongue. The accompanying fever is for 
some days, and even weeks, of daily occurrence, the pa- 
roxysms coming on in the afternoon. The stools are usually 
more deficient in bile than when in a healthy state ; and in one 
case which I have recently seen, were entirely white. This 
child was invariably attacked with convulsions whenever the 
alvine evacuations gave evidence of the deficiency of the 
biliary secretion. After the disease has continued for a few 
weeks, a sensible enlargement of the right hypochondrium 
may be discovered on a close examination. Cough will often 
be present with the other symptoms ; but the absence of expec- 
toration, and the stethescopic signs, will be a sufficient diagno- 
tic mark of the nature of the cough. 

Treatment. — This must be directed according to the vigour 
of the child. In general, this congestive condition of the liver, 
and the inflammation of the mucous membrane, which is usually 
its attendant, demand the early employment of blood-letting, 
either by means of leeches or the lancet. It is by the early 
adoption of this course, that some of those fatal affections of the 
bowels, so common in our country, are to be prevented. 

It is, indeed, rare that the physician is called to see a child in 
the forming stage of these affections ; but if there exist any of 
the evidences of hepatic disease, it may be regarded as a pre- 



DIGESTIVE SYSTEM. 229 

cursor of such diseases ; inflammation of the mucous mem- 
brane of the bowels, or cholera infantum, so frequently follow- 
ing such a condition of the liver. The loss of blood, therefore, 
is one of the most important remedies, and should in all cases 
precede the administration of other remedies. Cathartics espe- 
cially should be avoided until after the abstraction of blood, and 
then those only of the mildest character employed. Dr. Martyn 
Paine has some very judicious remarks on the treatment of dis- 
eases of this nature ; # remarking, that the lancet is far prefer- 
able to leeches, especially after the age of two years ; and at 
all ages, when there is much arterial excitement, it requires 
blood-letting in some form, as much as any disease of child- 
hood. When the child is unable to bear the loss of blood from 
the arm, leeches to the anus are indicated. Bleeding from 
their bites should be carefully watched, as from the highly 
vascular condition of the part, it may become excessive. This 
course, with the warm bath and fomentation, or poultices to the 
abdomen, and occasional doses of castor oil, will almost certainly 
effect a cure, especially when aided by a proper diet. 

CONSTIPATION. 

Costiveness in children demands an early attention, from 
whatever cause it may proceed. In the aged, on the contrary, 
although it should be obviated, yet the hazard of leaving it un- 
attended to is not so great as at the other extreme of life, when 
digestion and assimilation are very rapidly performed. 

Besides this ordinary costiveness, arising in sucking infants 
and children, that species occurring immediately after birth, 
and usually known by the retention of the meconium, very pro- 
perly comes under the present head. It will, on this account, 
be regarded as one kind of constipation peculiar to children. 

Etiology. — The remote cause of this condition is often diffi- 
cult to ascertain. In new-born children it may sometimes 
arise from pressure on some portion of the mass of the nerves, 
whereby the bowels are in a degree paralyzed. The peristal- 
tic motion, however, being of an involuntary nature, is but 
little under the influence of the nervous system, continuing, it is 
said, even after the division of the eighth pair of nerves, and 
becoming more active, Magendie asserts, as animals become 
more debilitated. According, however, to the statements of 
MM. Tiedemann and Gmelin, by the mechanical irritation of 
the eighth pair of nerves, in the plexus surrounding the 



* Medical and Physiological Commentaries, by Martyn Paine, M. D., A. M. t 
New-York, 1840 ; vol. ii. p. 523. 



230 DISEASES OF CHILDREN. 

oesophagus, the peristaltic action, both of the stomach and intes- 
tines, is increased. If this be so, the converse must also be true ; 
and the defect of stimulus, in some degree, would arrest the 
motion of these parts. 

The small quantity of the meconium may also be the cause of 
its retention ; for experiments have shown, that the peristole 
is more distinct, the greater the quantity of the contents of the 
intestinal tube. A practical deduction may be drawn from this 
fact, as it warns us not to be too anxious to administer to young 
infants purgatives, on the non-appearance of the meconium, but 
wait until the natural actions are excited by the means which 
nature has provided. 

The peristaltic motion appears, also, to be in some measure 
under the control of the neighbouring organs ; for at every in- 
spiration, the stomach is pressed on by the diaphragm. Free 
and strong respiration, therefore, and the crying of the infant, 
will often effectually excite the action of these parts. 

Tissot considers the spasmodic condition of the sphincters of 
the anus as occasionally a cause of the retention of the meco- 
nium. Such can hardly be the case ; but it is probably connected 
with a want of energy in the muscular coat of the intestines. 

Older children often become exceedingly costive, from the 
qualities of the nurse's milk, when sucking, or from some acci- 
dental cause connected with the nature of the food, or a sluggish 
state of the liver. 

Habitual costiveness is often observed from very early infancy, 
and appears to be strictly an hereditary affection. This should 
be early attended to ; for although there does not exist so much 
danger in costiveness arising from this cause as from the others, 
yet it cannot continue long without producing unpleasant symp- 
toms, such as colic, flatulency, etc., and even ultimately, as I 
have seen, becoming a cause of inflammation and dropsy of the 
brain. During the period of lactation, it is not unusual for 
mercenary nurses to give laudanum frequently to the children 
under their care, for the purpose of quieting them. This habit is 
invariably followed by a costive state of the bowels. Not only 
do opiates produce this effect, but the habitual use of purging 
medicines is generally followed by a similar state of the bow- 
els: the former causing it directly by its sedative effect, the 
latter, indirectly, by destroying the irritability of the mucous 
membrane, and thereby rendering it insensible to the ordinary 
stimulant of the food, or biliary secretions, and causing the re- 
petition of larger doses of cathartic medicine necessary to pro- 
cure the requisite discharge from the bowels. The effect of an 
ordinary cathartic is always to cause a costive condition to 
follow. 



DIGESTIVE SYSTEM. 231 

Semeiology and Pathology. — These do not demand much 
notice, as much that relates to them has already been described 
under the preceding head. It will suffice to observe, that 
after the meconium has passed, the child usually has from two 
to four alvine discharges daily, of a light yellow colour, without 
fetor or any acid odour, and free from curdy substances or solid 
lumps. From the rapidity of the digestive process, defecation 
is a frequent act, especially in young children, and on this 
account their bowels are often freely moved, having not less 
than two discharges in the day. When, therefore, but one is 
observed to occur in sucking children during that period, mea- 
sures ought to be forthwith adopted to secure to the bowels 
their normal action ; for even this deviation is a sign of disorder 
sufficient to render the interference of art necessary. Such a 
change will sufficiently point out the disease, without waiting 
for its more distressing symptoms of colic, abdominal inflam- 
mation, or even convulsions, to which it sometimes leads. 

The pathology of the disease, generally speaking, is in the 
torpor of the peristaltic motion of the bowels, or in a want of 
tone in the part. These two conditions usually exist together, 
unless the want of action has been induced by the habitual use 
of narcotics. 

Treatment. — It has been supposed by many that the meco- 
nium exerts an injurious influence on the mucous membrane, and 
consequently affects the health of the child, and that its speedy 
removal is necessary. It is, therefore, a very common practice, 
almost immediately on the birth of the child, to give it a dose 
of castor oil, to insure an evacuation of this substance. It 
however possesses no irritating or chemical quality, by which 
it can be injurious, in any other way, than by a prolonged 
retention of it in the bowels, when symptoms arise like those 
attendant on obstinate costiveness. It is, therefore, unnecessary 
to resort immediately to measures for its removal, as means are 
naturally provided for this purpose. The peculiar properties 
of the colostrum make it a natural laxative. The milk first 
secreted contains more serum and butter, and less caseum ; the 
microscope detects a difference in the milk globules, which are 
irregular, and have more the appearance of oleaginous particles 
than of these globules, and exhibits a larger proportion of fatty 
matter. For these and other interesting facts we are indebted 
to the researches of Dr. Donne.* If it is left, therefore, to the 
operations of nature, it will be found that the meconium will be 
discharged in most instances without artificial assistance. The 
use of any medicine must, as a general rule, be regarded as 

* British and Foreign Medical Review, vol. vi. p. 182. 



232 DISEASES OF CHILDREN. 

injurious, as the object of medicine is but to create a tempo- 
rary disease for the removal of another ; and only applicable 
when the disease demanding it is itself the greatest source of 
danger. How great is the hazard, therefore, to commence by 
giving the child, when uncalled for, active medicine, which at 
once creates a diseased action in the tender mucous membrane, 
the healthy integrity of which it is so necessary to preserve, 
where digestion forms the principal part of the actions of the 
economy. 

Where, however, the meconium is retained for three or four 
days, and the child manifests the uneasiness attendant on cos- 
tiveness, it will then become requisite to interfere for its removal. 
This should be at first attempted by an enema of simple warm 
water, or of molasses and water. If this is not sufficient, a 
teaspoonful of castor oil, as the least irritating, will generally 
suffice for its removal ; but even this should, if possible, be 
avoided, as the good effect following the use of cathartics, in 
any form, is often overbalanced by the disturbance of the 
system, which not unfrequently ensues on the early commence- 
ment of medicine. 

If the secretion of milk do not take place in two or three days, 
it will be necessary to feed the child with a little milk and water 
sweetened ; this of itself will generally excite the intestines to 
action. It has been the custom in Germany to give the child 
nothing more than a luke-warm water, before the secretion of 
the milk. A little milk and water is probably the best, as it 
approaches more closely to the natural nourishment of the child. 

Should a tumefaction of the abdomen be observed, together 
with the usual symptoms of colic, shortly after birth, without 
any appearance of the meconium, and especially if measures 
have been used to open the bowels, we may have reason to 
suspect an imperforate condition of some of the lower intestines, 
which may be ascertained on a proper examination, which 
should always be made. 

It sometimes happens, in consequence of the intestines being 
lined with a thick, tenacious mucus, that the bowels remain 
inactive, notwithstanding the use of the measures above men- 
tioned ; enemata may, under these circumstances, be made 
more stimulating, by a mixture of castor oil. A suppository 
of soap will also be found efficacious in exciting the motions 
of the intestines. It is much better to resort to these measures, 
in almost all their varieties, than to use any active or stimulating 
cathartic, as the meconium is almost always found in the large 
intestines, being the progress of foetal digestion, and resembles 
the feces in the colon and rectum of an adult. So uniform is 
this result, where opportunities have occurred to examine new- 
born infants after death, that where it has been found in the 



DIGESTIVE SYSTEM. 233 

small intestines, it has ascended there, in all probability, by a 
true anti-peristalic movement, as it is evidently no more its 
proper situation than that of ordinary fecal matter. Remedies, 
therefore, are more suitable to these cases when given by the 
rectum, as it is the lower intestines alone which require stimu- 
lating. 

When sucking infants are troubled with constipation, the 
mother or nurse should pay particular attention to her food, 
and use such as is of a laxative nature; for all the means used 
for its removal, by giving laxatives to the child, are generally 
but temporary in their effects, and ought only to be used to 
relieve urgent symptoms. It is often sufficient for her to take 
occasionally a purgative of some of the neutral salts, which, if 
largely diluted, will reach the circulation, and impart a laxative 
quality to the milk. This, together with some change in the 
infant's diet, will in most instances effect a change in its habit. 
Let the child therefore be fed, in addition to'what it sucks, with 
a little chicken water, milk and water sweetened with brown 
sugar or molasses, or with manna dissolved in it by boiling. 

Should these means fail of relieving habitual costiveness, 
while the mother continues the use of occasional doses of 
aperient salts, the child's abdomen may be covered over with 
a poultice, on which a little pulverized jalap or rhubarb has 
been sprinkled. As before remarked, we ought to avoid the use 
of purgative medicines in sucking children; but when they 
become necessary, those of the most unirritating nature should 
be used ; such, also, as are recommended below, proportioned 
to the age of the child, may be employed. 

Older children are at times troubled with costiveness, which, 
for the most part, arises from the quality of their food ; this is 
much more easily cured than if it occur from any hereditary pre- 
disposition. An alteration in the ordinary diet is the first step; 
and among the best articles to be used with the daily food is 
ripe fruit : children always crave it, and when perfectly ripe 
and fresh, may freely be allowed its use. A large draught of 
cold water, taken early in the morning, will often relieve it. 
In place of ordinary table salt, phosphate of soda may be used in 
their food ; its taste nearly resembles that of the muriate of soda, 
while its laxative properties are much greater. From its pure 
saline taste it makes an admirable laxative for children, and 
may be given agreeably to the subjoined prescription;* or 

* ~fy Sodse Phosph., ^ss. 
Aquae Bull., q. s. 
Amyl. Marantse, gss. 
Sacchar., q. s. 
ft. Gel. To be taken ad libit. 
30 



234 



DISEASES OP CHILDREN. 



cream of tartar, in combination with other laxatives, will be 
found useful.* 

Some tonic laxative may be at times necessary, and the 
syrup of rhubarb is a good medicine where such a purgative 
is required. In general, however, either of the subjoined for- 
mulse will be adequate to the removal of costiveness, if attention 
be at the same time paid to the food.f 

In some obstinate cases, calomel, jalap, and scammony may 
be required ; other measures ought, however, to be faithfully 
tried, together with the assistance of suppositories or enemata, 
simultaneously, before drastic cathartics are resorted to. 

In the Hopital des Enfans, where there is great experience, 
from the multitude of cases, the subjoined prescription is in 
common use, when the cases are extremely obstinate, and it 
is said, by M. Jadelot, with uniform success. J 

Aloes has at times succeeded, when most other measures 
have failed. Dr. Dunglison prescribed with success, in a child, 
twelve months old, a drachm of aloes in an ounce of simple 
syrup ; a teaspoonful of which was given every two hours, to- 
gether with a grain of calomel and four grains of jalap, which 
had been previously administered. This was resorted to after 
ineffectual attempts had been made to procure a passage from 
the bowels by other powerful means. The whole of this 
syrup was taken before an evacuation followed. Another child, 
aged six months, took three drachms of aloes before the bowels 
were moved. 

It is well not to persevere in the use of powerful cathartics, 
but to resort to other measures where the constipation is obsti- 
nate. The general relaxation produced by a warm bath, to- 
gether with leeches to the abdomen, will often have a very de- 
cided effect in unlocking the secretions in the abdominal viscera. 
Frictions, also, with camphorated oil, to the lumbar region, have 
been recommended to stimulate the nerves of the part. 



* ~fy Potassae, Sup. Tart., 3ij. 
Mannae, §ss. 
Aquae Fervent., ^iv. 
Syrup. Aurantii, 5iij. M. 
One half to be given at bed time, and 
the remainder in the morning, to a child 
from four to eight years of age. 

t fy Fol. Sennae, 3ij. 
Pulp. Tamarind, §j. 
Sem. Coriand. Contus., 3j. 
Sacchar. Com., §ss. 
Macerate for four hours, and strain. 
Two tablespoonsful for a child of three 
years. 



T$c Inf. Sennas, gij. 
Pulp. Prunae. ^iv. 

" Tamarind, ^ss. 
Syrup. Simpl., lbj. 
01. Carui., gt. xx. 
ft. elect. 
A teaspoonful for a child three or four 
years, at bed time. 
t fy, Fol. Sennas, 3iij. 
Sodae Sulph., 3ij. 
Mannae, §j. 
Aquae, §iv. M. 
Steep the senna for four hours in boil- 
ing water, then add the salts and mannae. 
A tablespoonful of this mixture to be 
given repeatedly, until an evacuation is 
produced. 



DIGESTIVE SYSTEM. 235 



WORMS. 



The existence of parasitic animals in man has been long a 
matter of observation, and from a very remote period the 
subject of speculation ; for it appears to have received the spe- 
cial attention of Hippocrates and Galen. Pliny, also, notices 
the presence of worms in various parts of the bodies of men 
and other animals. In addition to those of the class of intesti- 
nal worms, which is the subject of the present chapter, a vast 
number of the insect and reptile tribe has been described as 
existing in various parts of the body, as well as within the in- 
testinal tube. The writings of Schenkius, Marcellus Donatus, 
Borelli, and others, contain, also, descriptions of various kinds 
of animals, besides insects, that have been discharged from the 
body, such as frogs, lizards, serpents, etc. ; while every organ 
of the body, even the blood-vessels themselves, have been 
found, by the microscopic philosophers, to be the abode of num- 
bers of animalculi.* 

Some of these accounts, written during the sixteenth, and at 
the commencement of the seventeenth century, are great exag- 
gerations of some simple occurrence, similar to what is seen at 
the present day ; for occasionally there have been voided both 
larvae and perfect insects, of forms entirely different from in- 
testinal worms, so commonly discharged from the bowels of 
children, and to which a fruitful imagination has given the 
appearances above mentioned. Such instances have sometimes 
been met with; and Dr. Bateman mentions the discharge, from 
the anus of a young woman, of several larva? of the Tenebrio 
molitor, L., or meal worm ; and in another instance, of the larvae 
of the Musca domestica, or common fly. He also refers to 
Forestus, as describing a species of caterpillar by vomiting, and 
of the dejection of several scarabei. Accompanying the paper 
of Dr. Bateman. are figures of grubs, seen by Dr. Cheyne, 
which were discharged from the bowels. f 

It is unnecessary, and entirely foreign to the object of these 
remarks, to enter into an account of the supposed insect origin 
of various diseases. Measles, small-pox, hydrophobia, syphilis, 
petechias, elephantiasis, and numbers of others, have been re- 
ferred to the presence of insects in the different tissues, as their 
cause. The morbid effects of marsh malaria have, by some 
ancient authors, been attributed to myriads of animalculi sus- 



* Hist. Naturalis et Med. Latorum Lumbricorum intra Hominem et Animalia 
Nascentium, Auct. D. LeClerc, 1718. 

t Account of Larvae, etc., discharged from the Human Bowels, by T. Bateman, 
M. D.; Ed. Med. and Surg. Journ., vol. vii. 



236 DISEASES OF CHILDREN* 

pended in the air, and entering the body in the act of inspira- 
tion. Such ideas, however, are but the speculations of the 
imagination ; having no foundation in fact, for they are desti- 
tute of the least proof adduced for their support. 

It is only to that class of entozoa, which so commonly infests 
the intestines, and becomes either the cause of much disease 
and suffering, or the evidence of a great loss of energy in the 
digestive system, and thereby needing the interference of art 
for their removal, that the present remarks are necessarily 
limited. 

It is certainly a strange idea, which was advanced some 
years since by Roederer, and Wagler, in his treatise on the 
mucous disease, that they are useful for the consumption of the 
superfluous nourishment, and thereby prevent plethora. Dr. 
Butter, also, adopted the same views, and considers them of 
very little importance in the production of disease in children. 
He thinks that although they may exist in disease, they are 
neither the cause nor a symptom of disordered affection. 
He regards them as positively useful, by their movements, in 
promoting the peristaltic motion of the bowels, and thus assist- 
ing in the evacuation of the morbid secretions. Dr. Rush, also, 
from the frequency of their occurrence in all animals, without 
apparently being accompanied by disease, is disposed to adopt 
the opinion, that they are in some respects useful, in consuming 
the superfluous nourishment which all young animals so freely 
take, and even suggests the idea, that perhaps some children 
may be disordered for want of them, as they are found, he 
says, more frequently in stout and vigorous children, than in 
others. He is of opinion, also, that there exists no such dis- 
ease as the idiopathic fever, which has by some been attributed 
to worms ; and adopts the views which have been held by the 
aborigines, that the discharge of worms is to be referred to 
the fever, and not the existence of fever to the worms. In 
some cases, however, he admits that they cause anomalous 
symptoms, which call for the use of anthelmintic remedies in 
combination with others.* 

A number of monographs have been written on the subject 
of intestinal worms, but k the best which has appeared on the 
subject, probably, is the classical production of Rudolphi.f It 
is unnecessary to consider the five different families, and their 
various species, which are treated of at large by this author 
and by Frank.J as some of them are not intestinal worms, the 

* Enquiries, vol. i. p. 203. 

t Entozoor. sive Vemium. Intest. Histor. Nat. Auctore Carlo Rudolphi : Amster. 
1811. 
t De Curand. Horn. Morb. Epit., Lib. vi. 



DIGESTIVE SYSTEM. 237 

only species which naturally forms the subject of the present 
essay. A compendium of the natural history of all these en- 
tozoa, will be found in Dunglison's Commentaries on the Dis- 
eases of the Stomach and Bowels of Children. 

The worms that chiefly infest the intestinal canal of children 
are the following : the Ascaris lumbricoides, Tricocephalus dis- 
jDrtr.Oxyuris vermicularis, Strongylus gigas, Distoma hepaticum, 
Taenia solium, Taenia lata. 

The Ascaris lumbricoides, or long round worm, resembles 
very much the common earth worm, (Lumbricus terestris, L.) 
It is found in every part of the intestinal tube, and has even 
been found in the pancreatic and hepatic ducts, and occasion- 
ally in the gall bladder. Sometimes it has been vomited from 
the stomach, and is even in the oesophagus and pharynx. 
Andral mentions the case of a child who was suddenly seized 
with convulsions, while apparently in good health, and died 
with symptoms of suffocation. On post-mortem examination, 
one of these worms was found to have ascended from the 
stomach, and attempted to crawl into the glottis, which caused 
the spasmodic closure of the orifice and the death of the child. 
At other times they have been seen entirely in the air-passages, 
having probably ascended the oesophagus, and found their way 
into the trachea, and even the bronchiae, before they produce 
death. A case of this kind is recorded by Haller, of a girl aged 
ten years, who died from suffocation, caused by two of these 
animals in the trachea.* M. Blandin also mentions the case of 
a child that was suffocated by a large Ascaris lumbricoides, 
which had found its way into the trachea and right bronchiae. f 
A still more remarkable case is recorded in the Archives Gen. 
de Med., for January, 1836, where thirty-seven of these ani- 
mals were discovered in the trachea and bronchiae of the right 
side. The patient was suddenly seized on the third day before 
her death with dyspnoea and general distress, which increased 
until she died from convulsions. Besides those seen in the air- 
passages, there were thirty-six in the intestines. 

They have at times existed in immense numbers, and passed 
off, rolled together in the form of a ball. The colour of this 
w r orm is generally a pale red, but it occasionally varies from 
this, according to the colour of the fluid in which it happens to 
have been lodged. Its length is usually three or four inches, 
and it has been found even as long as fifteen inches. 

The Tricocephalus dispar, or long thread worm, is about 
an inch and a half to two inches long ; the head is acute ; the 

* Opuscul. Patholog. Lausanne, 1768, p. 26. 
t TrailS d'Anat. Topographie, p, 199, 



$38 DISEASES OF CHILDREN. 

body striated on the fore part ; the tail about twice the length 
of the other portion, and terminates in a hair-like point. The 
colour of this animal resembles the preceding, and like it, is 
also found in the horse, ox, ass and hog. It usually inhabits the 
coecum of sickly children, and is rarely in any other part. 

The Oxyuris vermicularis, maw-worm, or thread worm, has 
the appearance of the ends of thread. The name maw-worm 
is not derived from the occasional migration of this worm to 
the stomach, but from the sympathetic irritation it creates 
there. It is usually found about the rectum, and is the kind 
known by the name of ascarides. These are often also seen in 
masses, rolled up in the form of a ball, completely covered 
with mucus. They are more prevalent in the spring than at 
any other season of the year. They do not remain exclusively 
in the rectum, but occasionally find their way into the external 
parts of generation of females, and cause a great itching and 
leucorrhal discharge. This kind often exists in the intestines 
of the foetus and new-born children. 

The Strongylus gigas is a worm of a deep red colour, and 
measures in length from four inches to three feet, and in breadth 
from two lines to half an inch. It is chiefly found alive in the 
kidneys, and sometimes, although rarely, in the intestines. 

The Distoma hepatictim, or fluke, is a flat obovate worm, 
with a large abdomen. The size of this species is about an 
inch in length, and from four to six lines in the breadth. Its 
colour is a yellow, greenish, or brown. 

It is found in the gall-bladder, and occasionally in the intes- 
tinal canal It is very Common in all kinds of quadrupeds, 
fishes and reptiles. Athough discovered in all parts of the in- 
testinal canal, it is more common to meet with it in the liver ; 
and when abundant in that of the sheep, is the fatal disease 
among them known as the rot. It is not satisfactorily ascer- 
tained whether these parasites are the cause or effect of this 
disease. 

These worms have been seen in the gall-bladder, vena 
portarum, ductus choledicus, and parenchyma of the liver, and 
occasionally in the intestines of children that have been from 
time to time dissected. 

The Taenia solium has a broad, depressed, articulated body ; 
the joints obtuse, anterior short ; the next obtuse, and the re- 
maining oblong. The size of this worm is usually a 'few feet, 
but occasionally of great length. Robinus found, on dissecting 
a man that had died, after having discharged fragments of 
tape worm, the worm extending through the intestines, from 
the pylorus to within a few inches of|the anus, and measur- 
ing about thirty feet. Bremser mentions a case, in which one 



DIGESTIVE SYSTEM. 239 

hundred and fifty feet of tape worm were discharged by stool. 
Frank speaks of one forty-seven cubits in length. It has even 
been stated, that they have been discharged six hundred feet 
long. This, although enormous, is exceeded by that stated in 
the Copenhagen Transactions,* where a case is given of a tape 
worm measuring eight hundred ells, or upwards of seventeen 
hundred feet ! Such an extreme length is scarcely credible, and 
mast have arisen from some error arising, perhaps, in the mea- 
surement, taken probably at different times, when different por- 
tions were discharged. 

The taenia inhabits principally the small intestines, where it 
is often curled up in a roll, and is felt by the patient as he 
moves about in bed. At other times it is lengthened out to the 
whole extent of the intestinal tube. It is occasionally exceed- 
ingly distressing, from the continual motion, which has been 
described as a species of convulsions of the animal. Other 
worms may exist at the. same time with the taenia ; and both 
the Oxyures vermiculares, and Ascarides lumbricoides, have been 
discharged, with a portion of taenia, on the operation of an 
active vermifuge. 

The Taenia lata, or broad tape worm, is characterized by the 
head and marginal depressions being oblong, without any 
neck ; anterior articulation rugous : the other broader, and 
almost square ; the last one somewhat elongated. It is nearly 
flat, and measures from ten to twenty feet in length ; it is of a 
white colour. This species is of very rare occurrence in the 
human body. 

Etiology. — The most remarkable predisposing cause of 
worms is climate ; at least so it would appear from the writings 
of Hasslequist, Linnaeus, Rudolphi and Roscoe, with reference 
to the taeniae ; the Taenia solium being more common in Egypt, 
Italy, Holland and England. In Switzerland and Russia, the 
Taenia lata is of more ordinary occurrence than the other spe- 
cies. Neither of these are very often met with in the United 
States ; and tape worm may be regarded as rather a rare 
disease in this country. 

Childhood is the time of life that greatly predisposes the 
system to worms ; accordingly we find them at every period of 
childhood. Cloquet mentions, that at the Salpetriere, where 
none but aged persons are received, there were scarcely any 
of these parasitic animals found on opening the bodies of the 
deceased ; but at the children's hospital nothing was more com- 
mon than to find them, and sometimes in great numbers. The 



* Referred to by Dr, Stokes, Lond. Med. and Surg. Journ., May, 1834. 



240 DISEASES OF CHILDREN. 

Oxyures vermicular es, and Ascarides lumbricoides, are those most 
frequently found in children. The taeniae are rare in children, 
but occasionally exist in youth. 

Other predisposing causes are debility of the digestive organs, 
whether induced by an hereditary condition, or whether acquired 
by imperfect or insufficient food, or by a damp, cold, or insalu- 
brious residence. They have been compared by Frank to 
parasitic plants, which thrive best in poor and uncultivated soil, 
while the vigorous and fertile fields present but few of these 
dependents on other living plants and shrubs. 

The origin of worms in animals is as unsettled now as it was 
in the time of Aristotle ; and there is no department of medi- 
cal science, either physiological or pathological, of so much 
interest, as the presence of worms in the intestinal canal, and 
the various cavities and tissues of the system. The cause — 
the origin of their existence — still remains one of the most in- 
scrutable things in nature, and is a subject which has occupied 
the attention of natural philosophers in every age. 

The opinions of those who have made it the subject of inves- 
tigation may be classed under two heads ; those who believe in 
spontaneous generation, and those who are of opinion that the 
ova of these animals have been introduced into the body. 

Almost all the writers of antiquity adopt the opinion of 
equivocal generation, and are supported among the moderns by 
Buffon, Needham, Patrinus, Rudolphi, Bremser, Stokes, and 
others. It is explained by being a formation analogous to the 
organization of a portion of lymph thrown out on a serous 
membrane, which afterwards becomes organized, and acquires 
all the properties of life. When it is separated it becomes an 
independent animal ; the difference being, that in one case the 
organized mass remains adherent, and in the other is separate, 
forming a new creature. According to some, intestinal worms 
are formed from partially assimilated nutriment in the digestive 
tube ; the portion not taken up becoming a living animal. 

Those who maintain the idea that they spring from without, 
and are the product of ordinary generation, are Harvey, Lin- 
naeus, Gadd, Unzer, Tissot, Leeuwenhoeck, Muller, Good, and 
most of the physiologists of the present day. They have en- 
deavoured to show that all these creatures have been found in 
some situation out of the body, as the Distoma hepaticum in fresh 
water; the Taenia lata in muddy water, in rivers and in wells ; 
the Ascarides vermiculares in marshes, and about the roots of 
trees, etc. Wherever a great difference in their appearance is 
manifest, it is attributed to the effect of a different situation, and 
a modified developement from this cause. 

One of the principal difficulties of this theory, is the existence 



DIGESTIVE SYSTEM. 241 

of parasitic animals in the foetus of different animals, which 
have at times been discovered. The ovum in such cases must 
be exceedingly small, to have been received by the mother and 
transmitted through her blood-vessels and placenta to the foetus, 
and there developed into the perfect animal. Rudolphi and 
Blumenbach have given instances in which taeniae have been 
found in the intestines of new-born lambs and puppies; and 
Forman has discovered the Di stoma hepaticum in the liver of 
the foetal sheep. Entozoa have also been seen in the intestines 
of the chick which has just broken the shell. Brendel has seen 
the taeniae in the human foetus in utero. Hoking describes a 
foetus in which the intestines contained a number of small 
worms, and another in which a large Ascaris lumbricoides was 
found in the stomach. 

To account for all these different occurrences is certainly a 
difficult subject ; but for its explanation we need not resort to 
the doctrine of equivocal generation. It is not necessary, 
either, that all the parasites found in animals come from with- 
out, and that they exist in ponds or other places, and are first 
taken into the mouth, either as food or drink ; for some appear 
to be so uniformly found in a particular part of the body, that 
it would seem to be both their proper nidus and habitation, 
like other parasitic animals, as the larvae of certain insects, 
which find their food and habitation only on one kind of plant. 
Cuvier observes, that " the entozoa are remarkable, because a 
greater number inhabit the interior of other animals, and there 
can only propagate. There is scarcely a single animal that is 
not the domicil of several kinds, and those which are observed 
in one species, are rarely found in many others." These para- 
sites have no trachea, nor any other organ of respiration ; they 
therefore do not receive oxygen, except through the medium 
of the animal in which they live ; another strong presumptive 
proof that their proper habitation is in the animal they inhabit. 

It can be no objection to this theory, that the ova have to 
travel through the entire system, and be deposited in some 
tissue or cavity, in which the animal is found, even in the foetus ; 
for the probability is, that the ova are so extremely small, that 
they may be easily carried through the circulation, and then 
deposited in some of the cavities. That such may be the case, 
would appear to be not improbable from analogy. We know 
that the atmosphere is loaded with myriads of the eggs of the 
insect tribe, unknown to us until some circumstance occurs 
which arrests them in their flight, and furnishes them with a 
proper nidus for their developement. 

Whatever difficulties there may appear to be in the manner 
in which these parasitical animals are brought to inhabit the 

31 



242 DISEASES OP CHILDREN. 

different parts of the animal frame, it is certainly a great as- 
sumption to suppose them to exist there by spontaneous gene- 
ration. Although the multiplication of some of the lower ani- 
mals by sections, proves that there are other ways of reproduc- 
tion than by eggs, yet there is nothing in this to prove that 
any animal can be produced by a spontaneous formative move- 
ment ; while the existence of different sexes for reproduction, 
shows their mode of propagation to be like that of other ani- 
mals. And it is clearly unphilosophical to suppose them to be 
the result of a spontaneous organization, either of lymph, or of an 
excess of nutriment in the bowels; which organization, at the 
same time, also provides them with the organs for a continuance 
of their respective kinds. 

Morbid Anatomy and Pathology. — This is a subject of 
great importance in the treatment, or rather in the prevention, 
of worms ; for if the positive condition of the mucous mem- 
brane of the intestinal tube, on which the existence of these 
animals depends, could be ascertained, there would be little 
difficulty in the treatment. Unfortunately, however, it is but 
little understood in the present state of science, for worms 
have been discovered in every condition in which the intes- 
tinal tube has been found, and even when in a state of health. 

It is the opinion of Broussais, that they are the effect of a 
gastro-enteritis ; while Andral states that they have been found 
in every condition of the intestine, and usually lying in a 
quantity of mucus, and the little redness which has been noticed 
around them is rather the effect than the cause of worms. 
They have been seen in animals of great variety that have 
presented the appearance of perfect health, and, therefore, it 
w T ould seem that their existence is independent of any patho- 
logical condition other than a modification of vital energy, and 
therefore not traceable by ordinary dissection. As for the 
opinion of Broussais, and the practical consequences which re- 
sult from it, all experience proves its incorrectness ; for the 
most powerful means of relief of some of the serious symptoms 
of worms, are of a nature which would necessarily aggravate 
all the gastro-intestinal inflammation. Indeed, he deprecates the 
use of anthelmintics in the treatment of worms, on account of 
their stimulating effects on the mucous membrane of the intes- 
tinal tube. 

Semeiology. — It is extremely difficult to ascertain, by any 
symptoms, the positive existence of worms. Irritation in the 
stomach and intestines produces so many symptoms in remote 
parts, from the extensive sympathy of all parts of the body, 
that it is sometimes even difficult to trace the connection to the 
intestinal or gastric mucous membrane ; and when it is evidently 



DIGESTIVE SYSTEM. 243 

seated in the mucous membrane of the intestinal tube, it is no 
less difficult to ascertain with certainty its cause, all irritations 
in this part producing symptoms analogous to those of worms. 

The face is usually tumid and pale ; the inferior eyelids of a 
livid hue ; the nostrils itch, with occasional bleeding from the nose. 
The breath is very offensive, or of an acid odour, and the gums 
are covered with sordes. The upper lip is usually much swelled ; 
sometimes there is a difficulty in the speech, and even a loss of 
voice. The eyes are fixed and staring, and at times affected 
with strabismus ; the pupils are often dilated. At times there is 
pain in the head, and severe convulsions, vertigo, or delirium, 
sometimes follow a turgid state of the brain. To these symp- 
toms there is added a stubbornness of disposition, or a list- 
lessness. with occasional fits of terror. When asleep, the child 
appears to be affected with terrific dreams, and awakes in great 
alarm. The respiratory organs are also sympathetically 
affected, for the breathing is hurried, and at times difficult. 
There is also a dry, tickling cough, and sometimes of a convul- 
sive character ; pains also affect the chest, bearing a great re- 
semblance to pleurisy. Stethescopic examination will detect 
the sympathetic character of the pulmonary affection, and 
therebv enable us to form a diagnosis of the disease. All these 
symptoms may be regarded as symptomatic. 

The semeiology of the abdominal organs is of more impor- 
tance, in a diagnosis of the disease, than any of those above 
mentioned, which, although occurring in some form or other, 
are, it must be admitted, often fallacious. The appetite is va- 
riable, the hunger sometimes insatiable ; but notwithstanding a 
large quantity of food is devoured, emaciation rapidly increases. 
There is also nausea and vomiting, pains in the stomach and 
abdomen, and often a sudden enlargement of this part, which 
becomes tympanitic. Often there appears to exist an indescri- 
bable sensation of distress and gnawing in the stomach and 
bowels. There is also at times severe tenesmus, bloody stools, 
mixed with mucus, and other symptoms of inflammation in the 
large intestines. None of these symptoms are conclusive ; and 
the appearance of worms in the alvine evacuations is the only 
positive testimony of their being the cause of these symptoms. 

Such are the general symptoms of the presence of worms 
in the intestinal canal. There are others, which attend the 
existence of worms of a particular species, which appear to 
demand some attention. Thus the Ascarides lumbricoides, or 
common round worms, which are usually found in the ileon, 
although often existing without producing any symptoms of 
distress, when causing any uneasiness or pain, will excite it 
in the region of the umbilicus, either of an itching or spas- 



244 DISEASES OF CHILDREN. 

modic kind, resembling colic. The Oxyures vermiculares, 
or small thread worms, cause an intolerable itching about the 
anus, and a similar irritation of the nose and mouth, indu- 
cing a constant picking of the nostrils and mouth. When, also, 
there exists a feeling of great nausea and sinking at the 
stomach, the existence of these worms may be suspected, par- 
ticularly if accompanied by irritation of the rectum. The 
tsenise cause much greater distress than either of the others. 
The same voracious appetite occurs, as in the lumbricoid 
variety ; but there is a sensation of much greater weight and 
movement in the abdomen, with a pricking and gnawing of the 
stomach. 

Worms are by no means so dangerous as was formerly be- 
lieved ; the danger arises altogether from the violence of the 
sympathetic affections ; and convulsions, and inflammation of 
the brain, are the affections most to be apprehended from the 
irritation of these animals. At other times they exist without 
even causing any symptoms of their presence, which has in- 
duced the belief in the minds of some, that they are actually 
beneficial, by consuming the excess of nutriment, and thus pre- 
vent plethora. There can be no question, that the condition of the 
system which predisposes to worms is also productive of other 
diseases ; and the derangements, and even fatal consequences, 
which have at times followed the presence of worms, may be 
referred to the general disorder of the chylopoetic viscera, 
which gradually undermines the constitution, and which has 
too often been attributed to the presence of these animals : one 
of the symptoms of the effects of this deranged condition of the 
organs, so essential to the healthy performance of the functions 
of the system. This we see to be the case in persons sick with 
disorders affecting the digestion ; and in those of a delicate 
frame of body, which has been inherited from parents, in such as 
are affected with a scrofulous disposition, etc. ; all suffer more 
or less from derangements of the assimilating function, and are 
those most commonly affected with worms. In fevers, espe- 
cially in viriola, scarlatina, and measles, worms often abound 
in great numbers, and would therefore appear to arise from the 
condition of the system in these diseases ; for it will not be sup- 
posed that the diseases are caused by the worms. 

In violent fevers, worms have been observed to creep out of 
the mouth and anus. This is regarded as an unfavourable symp- 
tom. The contrary opinion is entertained by Hippocrates, and 
ancient authors generally, probably from considering worms 
as more frequently the cause of diseases than they are. and 
that their removal, either spontaneously or otherwise, is neces- 
sary for the cure of the disease. They have often been noticed 



DIGESTIVE SYSTEM. 245 

to make their appearance, on the approach of death, on the 
outside of the body, a strong presumptive proof of their occu- 
pying' the intestines as their natural habitation, and that their 
instinct leads them to forsake the animal which will no longer 
afford them support. 

None of the worms which infest the human intestines can 
be regarded as dangerous in themselves, excepting, perhaps, 
the taeniae. These often create a great and continued distress 
and irritation in the system; and the extreme difficulty of their 
expulsion, and the powerful remedies often required for this 
purpose, will at times endanger the life of the patient. Even 
after they have been removed, such is the violence of their 
irritation, that the distressing symptoms will continue for some 
days, from the habit which the intestines have acquired of 
putting on a morbid action. All the symptoms above enume- 
rated more frequently attend this kind of the entozoa than the 
others, and are sometimes greatly aggravated by the powerful 
measures taken to rid the patient of their cause. Convalescents, 
it has been observed, recover very slowly after fever, when 
affected with taeniae.* 

It has been asserted by some that worms have at times 
penetrated the intestines, and found their way into the cavity 
of the abdomen and other parts, and even exterior to the body. 
Hunerwolf gives an account of a case of enteritis where the 
worms had produced perforations; Heister and Coith, also, re- 
late instances of perforated intestines and worms in the cavity 
of the abdomen.f There are other instances on record of worms 
being found both within and outside of the body ; but they have 
been in every instance connected either with an abscess or an 
ulcerative process. It is scarcely probable that it should occur 
in any other manner,,for it appears so contrary to the nature of 
parasitic animals to migrate in this manner. 

Treatment. — As the predisposing causes of worms are 
such as affect the powers of the digestive organs, it will be 
necessary to adopt such general measures, during the continu- 
ance of the disease, as will restore these organs to their healthy 
vigour. Whatever, therefore, appears, from the peculiar con- 
dition of the child, to be the principal cause of this want of 
tone in the system, must receive our chief attention, otherwise 
the attempts to cure the disease by the ordinary remedies for 
destroying and expelling the worms, will be of little avail ; and, 
in some instances, will even be injurious, by their powerful effects 
on the mucous membrane, rendering the powers of digestion 



Frank, p. 268. t Dunglison, Op. Cit., p. 



4:2. 



246 DISEASES OF CHILDREN. 

more feeble than before. It is unnecessary to enter minutely 
into the details of this course ; it will suffice that a good 
substantial diet be adopted, when insufficient nourishment has 
been the cause ; or a change of air, where the circumstances in 
which the child has been placed, have rendered it probable that 
a want of free air may have produced a debilitated state of 
the system. At other times, tonics will be indicated to restore 
the digestive function to its proper tone. 

The remedies which are used to expel worms from the in- 
testinal canal, are prodigious in number. Besides that of an 
indirect nature, such as are mentioned above, for the purpose 
of restoring energy to the lost digestive powers, there are many 
which act in a direct way. and destroy the worms, either by 
expelling or by killing them by such means as are poisonous, 
or by such as act mechanically. Anthelmintics may therefore 
be divided into these three classes. A vast number of experi- 
ments have been made, to ascertain the effects of various agents 
on these animals, after they have been discharged alive from 
the body, for the purpose of ascertaining the medicinal sub- 
stance which would destroy them the soonest. They have 
been placed in cold and hot water, in infusion of aloes, in solu- 
tions of muriate of soda, oxymuriate of mercury, and other salts. 
They have also been immersed in brandy, wine and alcohol. 
They have also been placed in various essential oils, which it 
is unnecessary here to enumerate ; also in expressed oils, under 
the supposition that, like other vemicular animals, the spiraculse 
would thereby be obstructed, and the animals killed. We have 
seen, however, that there exist no respiratory organs in the 
parasitic worms infesting the bowels, and, as might be expected, 
they lived as long in these oils as in any other fluid. 

From all these experiments, very little if any satisfactory 
results have been obtained; for the accounts are exceedingly 
contradictory, and in some instances quite unexpected, as was 
the case in one instance related by Rosen Von Rosenstein, 
where a worm that was discharged from a child was kept alive 
a whole day in alcohol.* 

The most practical manner of treating the subject, is unques- 
tionably that wherein each species of intestinal worms is sepa- 
rately brought into consideration ; for although almost all the 
ordinary anthelmintics are applicable to every kind of Worm, 
yet each requires some modification of treatment, arising both 
from the nature of the worm, and the particular part of the 
intestinal canal it inhabits. 



• On the Diseases of Children. Translation by Sparmann, p. 230. 



DIGESTIVE SYSTEM. 247 

The worm most commonly met with is the Ascaris lumbri- 
coides, and it naturally demands our attention first. The first 
step in the treatment of these worms, is to administer a purgative 
of an active nature, as a combination of calomel and jalap, 
when the condition of the alimentary canal does not forbid 
the employment of so active an agent. If there exist any 
appearance of inflammation in the intestinal tube, such a course 
must be avoided, and one of a milder nature substituted, as 
castor oil. The brisk action of a cathartic will often remove 
a quantity of slimy matter which adheres to the worms, and in 
which they live, and prepare them to be acted on by such direct 
means as it may be necessary to use for their destruction. 
Formerly, calomel was very much in use as a vermifuge, but 
it is doubtful whether it possesses any power, other than its 
active effect as a cathartic; but in this mode, calomel, as well 
as other active purgatives, often at once removes many of the 
lumbricoides. 

The operation of calomel, or of any other purgative, should 
be thorough and effectual at once ; it will then remove a large 
quantity of mucus, in which the worms are lodged. Where 
there is much mucus present, it is often difficult to procure a 
good cathartic effect from calomel, even when combined with 
jalap or rhubarb to quicken its operation. Scammony has 
been found useful when this state of the bowels exists, in com- 
bination with calomel and sulphate of potash, which modifies the 
griping qualities of scammony, and forms an admirable cathar- 
tic in worms.* 

After the operation of the cathartic, which should not be 
often repeated, on account of the debilitating effects on the in- 
testinal tubes, it will be necessary to resort to anthelmintics, if 
the cathartics fail in expelling the worms. Of these there is a 
great variety, almost too numerous to record at length, and 
many of them, probably, are wholly inefficacious. 

The oil extracted from the seeds of the Artemesia santonica is 
an anthelmintic in common use, and is certainly very efficacious ; 
but from its strongly stimulating properties is rather hazardous, 
by exciting inflammation of the mucous membrane. 

The same remarks apply also to tansy, Tanacetum vulgare. 
The subjoined formula is the celebrated anthelmintic electuary 



* T$c Hydr. Subm., gr. v. 
Pulv. Scammon., 
Potassoe Sulphat., aa. gr. x. 
Sacchar. Alb. Pulv., gr. v. 
01. Cinnam., gt. j. M. 
ft. Pulv. No. vi. 
One every four hours, to a child three years old, till an effect is produced. 



248 



DISEASES OF CHILDREN. 



of Bremser.* At the same time an enema of similar ingredients 
should also be used.f It has also been applied externally, in 
the form of a poultice, made with camomile flowers boiled in 
milk. 

Common salt is a tonic in small doses, and acts as a cathartic 
in larger ; it has been used as an anthelmintic, in the dose of a 
spoonful every morning. It seems particularly to annoy every 
species of worms, and its use is well known to every farmer, 
as the best cure and preventive of worms in all kinds of ani- 
mals. Its ordinary daily use is of great benefit where there 
are children predisposed to worms, as the best prophylactic 
that can be employed. 

The Indian pink, Spigelia Marylandica, is a very powerful 
anthelmintic, long in use in the United States. Its effects are 
decidedly narcotic, and in an overdose producing dimness of 
sight, dilated pupils, and vertigo ; even terminating, it is said, in 
convulsions. These are not apt to occur, however, if the medi- 
cine be cautiously used. I have never known but one instance 
where the patient appeared to suffer from the effects of this 
remedy, and the unfavourable symptoms soon disappeared on 
stopping the medicine. It may be regarded as one of the most 
useful anthelmintics. 

Spigelia may be given, either in powder or decoction. Of 
the former, a child four years old may take fifteen or twenty 
grains every morning, followed by an active cathartic, after 
three or four doses have been taken. The decoction is the 
most eligible form for its administration ; and it may be given 
either mixed with coffee for breakfast, or sweetened and pre- 
pared like the usual beverage taken at that meal. It is made 
by boiling an ounce of the plant in a pint of water down to 
half a pint ; a half an ounce of which may be taken morning 
and evening, by a child five or six years of age, until the whole 
is taken ; when a purgative of an active kind ought to be 
given. This is almost invariably followed by an expulsion of 
the worms. 

Spigelia has also been given in the form of a syrup, made by 
boiling five parts of the plant for an hour, in ten parts of water. 
When the decoction has stood for twelve hours, it should be 



* T)c Flor. Tanaceti, gss. 

Pulv. Rad. Valerian, 3ij. 

Pulv. Jalapae, 3j. 

Potassse Sulph., 3ij. 

Oxymel Scillae, q. s. ut. M. 
ft. electuarium. 
A teaspoonful twice a day. 



t R- Artemesice Absynth., 
Rad. Valerianae, aa. §j. 
Cort. Aurantii, 
Flor. Tanacet., aa. gss. M. 
c. m. f. Spec. 
Two tablespoonsful being infused for 
a night, and strained ; the strained liquor 
mixed with a spoonful of fresh ox gall, 
to serve for the enemata. 



DIGESTIVE SYSTEM. 249 

strained and sweetened, and evaporated to the consistence of 
syrup. This syrup is to be taken three or four evenings in 
succession, in a quantity proportionate to the age of the child, 
followed by a dose of castor oil.* 

Spigelia is often advantageously combined with purgatives; 
and a very popular prescription is a mixture of senna and pink- 
root. The following prescription is from the Materia Medica of 
Drs. Wood and Bache.f Another excellent one is the combi- 
nation of pink-root and savine, as in the subjoined prescription. J 

It is unnecessary to mention any more of the narcotic class 
of anthelmintics ; those already mentioned will be found in gene- 
ral sufficient for the removal of the Ascaris lumbricoides. 

If these means, however, should fail, and the condition of 
the mucous membrane will allow of its use, spirits of turpentine 
will be very efficient against this kind of worms, as well as all 
others. It may be given, it is said, with perfect safety, even to 
the youngest children, as it does not produce so much irritation 
in the mucous membrane, as we might suppose, from its pow- 
erfully irritating effect on the skin. The dose is from half a 
drachm to two or three drachms, to children three years of age, 
mixed with milk, or beat up with the yolk of an egg, or, what 
is better, by combining it with castor oil. 

The bristles or pubes of the Dolichos pruriens is the best of 
the mechanical anthelmintics. It produces on the skin a most 
distressing itching; but no sensation of this nature follows its 
use when given internally, and the mucous membrane of the 
intestinal tube does not appear to be in the least affected. It 
is, at the same time, one of the safest and most effectual reme- 
dies for the lumbricoides, which generally appear after a few 
doses have been administered. The proper dose is from five 
to ten grains in syrup, followed by a dose of castor oil. 

Grained tin was formerly supposed to owe its efficacy to the 
presence of arsenic in a metallic state ; but it has been satisfac- 
torily ascertained that pure tin itself possesses all the anthel- 
mintic properties. It has also been supposed to act by the 

* Journ. de Connaiss. de Med., January, 1835. 
t fy, Spigelian, §ss. 
Sennse, 3ij. 
Mannse, fj. 
Foeniculi, 3ij. 
Aquae Bull., gj. M. 
Mascera per horam in vase leviter clause et cola, A wine-glassful to be 
given to a child from two to four years old. 

t # Rad. Spigel. Maryland, 3vi. 
Fol. Senna;, 3ij. 
Fol. Sabinae, 3ss. 
Aquae Bull., §iv. M. 
Preparation and dose as the preceding. 
32 



250 DISEASES OF CHILDREN. 

hydrogen it generates in the bowels, and that its efficacy is in- 
creased by its mixture with sulphur, by which sulphurated hy- 
drogen is formed. By others, its action is considered as purely 
mechanical, both annoying the worms, and exciting the peris- 
taltic action of the intestines. It is usually given in doses of 
one to two drachms, mixed with syrup, three or four days in 
succession, in the morning, followed by a cathartic. 

The principles on which the treatment of worms is founded, 
are the same in all ; but there are some differences in the differ- 
ent varieties which demand an alteration, which will make the 
remedies more particularly applicable to one class. Thus, 
owing to the situation in which the oxyures are found, in the 
rectum or lower portions of the intestines, the remedies may be 
often given by enema; that already mentioned will be found 
highly useful in the removal of these worms when they are 
situated at the lower extremity of the intestinal tube. Enemata 
of sulphate of iron, consisting of three or four grains dissolved 
in four or six ounces of water, or of equal parts of milk and 
lime water, or salt and water, or camphorated oil, are all very 
useful in removing these worms from the rectum. Infusions 
of valerian and garlic have also been used, for the same 
purpose. At the same time it will be advisable to administer 
an aloetic purgative by the mouth ; and the aloetic mixture of 
Evanson and Maunsell is probably the best for administration 
to children, as the liquorice tends to conceal the taste.* The 
anthelmintic properties of this mixture are greatly increased 
by the addition of half a drachm to two drachms of muriated 
tincture of iron. The operation of aloes is principally on the 
lower intestines, as it is believed to pass unchanged through 
the small intestines, probably from the difficulty of its solution : 
it is therefore particularly useful in promoting an action in the 
rectum, where these worms are principally confined, while its 
action from above will also tend to prevent these worms from 
moving from their usual habitation, and occupying, as they some- 
times do, higher parts of the intestinal tube. Any of these 
enemata should be daily used, and a purgative once or twice a 
week will, for the most part, be sufficient to remove them ; while 
a generous course of diet, and the habitual use of tonic medicines, 
where the state of the digestive organs seems to demand their 
use, will be necessary to secure the system against a return of 
them. The muriated tincture of iron is an excellant tonic for 



* Decocti Aloes Comp., §jss. 
Extr. Glycyr.. 3ij. 
Vini Aloet., 3ij. M. 
One or two drachms twice or thrice a day. 



DIGESTIVE SYSTEM. 



251 



strengthening the mucous coats of the intestines and stomach, 
and preventing the reproduction of the oxyures. It may be given 
in the dose of two to ten drops, largely diluted with water, or 
in the following prescription.* 

The taeniae are rare in children ; they require much the same 
course of treatment as the Ascaris lumbricoides, except that 
the difficulty of their removal demands often a constant re- 
course to the different anthelmintics. The prescription of 
Bremser, already mentioned, is one which, when followed by 
an active cathartive, and the immediate use of the empy- 
reumatic oil of Chabert, is remarkably successful, according to 
this celebrated German practitioner, as well as by Frank, f 
The empyreumatic oil differs but little from the oil of turpentine 
in its effects, and consists of one part of the empyreumatic oil 
of hartshorn and three of the oil of turpentine ; the dose for an 
adult is two dessert-spoonsful morning and evening. 

The celebrated remedy which was revived by Mad. Nouffleur, 
the male fern, Poly podium filix mas., was in use in the days of 
Galen and Dioscondes, as a remedy for tape worm. From 
the testimony of numbers of physicians in every country, it has 
been successful when every other remedy has failed. An in- 
stance of this kind occurred in the case of the late Dr. Jones, 
of this city ; all the varieties of anthelmintics had been used 
without effect, until recourse was had to a decoction of fern, 
when a worm measuring forty-five feet came away. 



GASTRITIS. 

Inflammation of the stomach is described, by the French wri- 
ters, as a disease by no means unfrequent among children. It 
is to MM. Saillant and Billard that we are indebted for the 
information we possess in relation to this disease, as it occurs 
in young children. The last mentioned author particularly 
records all that is known as to the pathology of the disease. 
Dr. Burns,J also, has a few practical remarks on this disease, 
which he observes is not common in infancy, nor is it discovered 
without much attention. 

Etiology. — This disease is at times of congenital origin, the 
researches of Billard furnishing us with instances in which the 
foetus was evidently affected with it. It is unnecessary here to 
ive the cases in detail ; the reader is referred to the work of 



I 



. Billard for the accounts of these interesting cases. 



* # Tinct. Ferri. Muriat., gt. x. 

Aquae Cinnam., §jss. 

Syrup. Simpl., §j. M. 
Two teaspoonsful every hour. 



t Op. Cit.,p. 290. 

t Principles of Medicine, including the 
Diseases of Women and Children, by 
John Burns, M. D., American edit. p. 727. 



252 DISEASES OF CHILDREN. 

When it arises in infants after birth, its causes do not differ 
from those occurring in adults. The irritation of irritating in- 
gesta, or of poisonous articles taken into the stomach, sometimes 
occurring accidentally, from the solution of a metallic oxide from 
the vessel in which the food has been prepared. Cold or wet 
applied to the surface of the body, also, will produce it, as in 
adults. 

Morbid Anatomy. — The stomach is found inflamed in dif- 
ferent parts of its structure, from which the disease has been 
arranged in different forms : that affecting the capillary vessels 
of the stomach, causing a ramiform capillary injection, or ap- 
pearing in patches or striae in the mucous membrane, or in the 
papilla; and villosities, has been distinguished by the name of 
erythematic gastritis. Another form is that in which the secre- 
tion of the stomach is principally affected, corresponding with 
the altered secretion of the mucous membrane of the mouth, 
and known, when it occurs in that part, as the thrush, or muguet 
of French authors. When these symptoms occur after the 
mouth has been affected with aphthae, there can be no question 
that the inflammation has extended to the stomach. The third 
form of gastritis is that affecting the follicular apparatus of the 
stomach, sometimes appearing under the form of small, white, 
round, slightly projecting granulations, with a black point at 
their summit ; at other times inflaming and ulcerating. The 
fourth variety is that denominated gangrene of the stomach, 
and consists of a true disorganization of its tissue. This last 
is rare in infants, but it has been found where the mucous mem- 
brane had become of a deep brown, and partially in a state of 
putrefaction, and diffusing an offensive odour. The shreds of 
the separated membrane were diffused in a dark coloured fluid. 
Another variety of gastric inflammation is the gelatinous soften- 
ing, as is described by M. Cruvielheir. The mucous membrane 
in this variety is found pale and colourless, and almost transpa- 
rent, as if macerated in water and reduced to a pulp, while the 
mucous follicles are in their natural state. This alteration of the 
tissue of the stomach is most evident at the greater curvature. 

These are the different results of inflammation of the stomach, 
condensed from the accounts furnished by MM. Cruvielheir and 
Billard, and they all arise from inflammation, varying in violence 
and seat, and modified by the constitutional vigour of the patient. 
All these varieties, although described as distinct, may yet 
occur together, and Billard has given a case in which such an 
assemblage of morbid phenomena was formed ; proving them 
to be the result of inflammation, varying from the causes above 
mentioned. 



DIGESTIVE SYSTEM. 253 

Semeiology.— The characteristic signs of gastritis are pain 
on pressure over the stomach, evident from the child shrieking 
or crying. The bowels are usually loose. If the child be old 
enough, he will describe the pain as of a burning character. 
In addition to these symptoms there is constant vomiting. 
There are often a continual coughing and difficulty of respira- 
tion, but the disease may be distinguished from pulmonary 
inflammation by the absence of vomiting in the latter. The 
expression of countenance is remarkably altered in gastritis. 

There is but little or no difference in the symptoms of the 
different forms of the disease, except that in the follicular variety 
there is often bloody vomiting. In that, also, which is known 
as the gelatinous softening, the symptoms are remarkable for 
their severity. The skin is cold, the pulse irregular ; the face 
is much wrinkled, and expresses great pain, while at the same 
time there is great prostration and insensibility, occasional! y 
alternating with severe pain. 

Treatment. — The first indication in the treatment of gastri- 
tis, is to allay the violence of the inflammation, by the abstrac- 
tion of blood, if the strength of the patient can bear the evacu- 
ation. It will rarely, however, be necessary to adopt general 
blood-letting in young children, in whom the prostration is 
often very great. In those that are older, where there is much 
tension of the pulse, the lancet is our main dependence. 
Leeches may in general, however, be safely applied on the 
epigastrium, followed by warm stupes. These, or cataplasms 
throughout the disease, are admirable means of lessening the 
inflammation, and should be constantly used. When the action 
of the blood-vessels is subdued, a blister may be applied over 
the affected part. 

Purgatives should be carefully avoided ; and if it become 
necessary to relieve the bowels, it should be done by means of 
laxative enemata ; even the mildest and least irritating laxative 
ought to be withheld from the stomach, much more those 
nauseating remedies, so useful in inflammations in general. 
Mucilages may be freely used, and the thirst satisfied with iced 
drinks. 

In chronic cases it has been recommended to use frictions 
with tartar emetic ointment ; but this cannot be employed 
without hazard, from the effect that antimony almost invariably 
exerts on the stomach, especially in debilitated or young sub- 
jects. Revulsion may, however, be made by stimulating baths, 
and the application of sinapisms or blisters to the lower ex- 
tremities. 



254 DISEASES OF CHILDREN. 



ENTERITIS. 

Inflammation of the intestines is of common occurrence in 
infancy, and in some instances assumes so great a difference in 
its symptoms, as to be one of the most difficult diseases at 
times to recognise. This arises from its occurring in every 
degree of intensity, and affecting so many different portions of 
the intestinal tube, whereby its sympathetic irritations vary in 
almost every instance. But these will be more particularly 
noted under the semeiology of the disease, and especially the 
remarkable difference between this disease in adults and youth, 
and as it occurs during the period of infancy. 

For the remarkable facts connected with this affection, we 
are indebted to Dr. Abercrombie,* and to those indefatigable 
French physicians, MM. Billardf and Valleix,J who have so 
ably investigated this interesting subject in the hospitals in 
Paris. 

Ettology. — This disease, like the preceding, has been found 
in children so shortly after birth, as to leave no doubt of its con- 
genital origin, it having existed both in an acute and chronic 
state ; and the extreme feebleness of some infants, no doubt, 
arises from inflammation of the first passages which has existed 
before birth ; for in some, in which there existed no other 
symptoms than excessive feebleness, extensive inflammation of 
the intestines have been found, and was the only abnormal con- 
dition existing. 

The high state of excitability in the mucous membrane of 
sucking infants, together with the activity of the digestive func- 
tion, renders it extremely liable to inflammation. Irregularities 
of diet, also, an error so frequently committed, is one of the 
most common causes of inflammation of the bowels. The per- 
nicious practice of administering purgative medicines on the 
slightest disorder of the child, is another very evident cause of 
inflammation in these parts. It is, therefore, of the greatest 
importance that this habit be not early acquired ; many a child 
has been sacrificed to the pernicious custom of using a cathartic 
immediately after birth, which not only is itself productive of 
direct injury, but, by rendering the bowels disposed to inaction 
without the repetition of this stimulant, increases the necessity 
of cathartic medicines. 

Semeiology. — The symptoms of enteritis in young infants differ 
greatly from those occurring in adults. In the latter, the abdo- 
minal region is the part mostly affected, the symptoms varying 

* Op. Cit., p. 46. t Op. Cit. p. 296, et seq. 

t Op. Cit., p. 462, et seq. 



DIGESTIVE SYSTEM. 255 

with the portion of the tube which is diseased. The progress of 
the disease is also much more rapid in the adult ; there are fewer 
complications, and the prognosis is much more favourable. In the 
new-born child there is but little febrile action ; the progress of 
the disease is slow, and death almost certain, and the secondary- 
symptoms often very numerous and variable ; although in some 
few there exists a want of these symptoms of complication, 
which occurs more especially where the disease is of congeni- 
tal origin. In children, however, where there is much febrile 
excitement manifest, other and distant parts often are the only 
parts which manifest any disturbance ; and, while in the adult 
the local tenderness is the most marked symptom, in infants 
there exist many marks of irritation in the pulmonary and ce- 
rebral systems ; so that there have existed severe signs of pul- 
monary inflammation, as would appear from the rapid and 
laborious breathing, while the physical signs gave satisfactory 
indications of the non-existence of disease in the thorax. Such 
cases must have been seen by almost every practitioner of any 
observation, and where the remedies applied for the relief of 
pulmonary disease have been unattended with any satisfactory 
result. Again, symptoms of cerebral irritation are very com- 
mon in children affected with enteritis. After the severest 
symptoms of inflammation of the brain, dissection has at times 
exhibited no remains of disease in the head, while severe inflam- 
mation has been found in the abdominal viscera. Such, how- 
ever, is the intimate sympathetic relation between the mucous 
membrane of the digestive passages and the brain, that in the 
treatment of the diseases of children this relation should con- 
stantly be borne in mind ; for serious diseases of the brain are 
often the result of inflammatory action in the digestive organs; 
a fact well known to the ancients, but more particularly pointed 
out by modern writers. The pathological sympathies are so 
great, that, according to some investigators, the meninges of 
the brain participate in an equal degree with the affection of 
the mucous membrane of the bowels, having at one time a 
chronic action, and at an other an acute character, according 
to the amount and degree of the primitive disease. Laborious 
and varied researches have been made on living animals, on 
animals that have been suddenly killed, and on men that have 
met with a violent death, for the purpose of ascertaining the 
natural condition, if possible, of the meninges of the brain, before 
coming to this conclusion.* 



* See a paper by M. Scouteltin, in the twenty-eighth volume of the Journal des 
Sciences Medicales. Also, Researches d'Anatom. et Patholog., etc. etc., sur le 
Cerveau, par J. Sabrioles. passim. ; Paris, 1826. 



256 DISEASES OP CHILDREN. 

With every allowance for the enthusiasm of those devotees 
of science, in regarding the cerebral meninges as affected with 
precisely the same shades of diseases as are found to exist in 
the mucous coat of the intestinal canal, no doubt can remain 
of the intimate relation between them, and of the danger arising 
to the brain from the existence of abdominal disease ; for the 
part only at first sympathetically irritated, may at last absorb 
the whole of the disease ; or what is of more common occur- 
rence, exist in connection with the original visceral affection. 

The most common symptoms of this disease are vomiting, 
diarrhoea, tympanitis, and abdominal pain, which is increased 
on pressure. Fever is often absent, but there is great heat on 
the abdomen ; this is so constant a symptom, that the physician 
should always examine the abdomen, and the surrounding 
parts, to ascertain the existence of morbid heat in the part. 
The heat, for the most part, is greater in proportion to the 
violence of the inflammation, although it exhibits exacerbations 
and remissions. As a general rule, the inflammation is at its 
height when the heat is the greatest, while at the same time 
there is violent thirst, dry skin, and cold extremities. The 
thirst is greatest in proportion to the extension of the inflam- 
mation towards the duodenum, according to the opinion of 
M. Broussais. 

In the early stages of the disease, it is difficult to distinguish 
it from ordinary bowel complaints. As it advances, the tongue 
becomes furred and dry ; there is great restlessness and wake- 
fulness. In the first appearance of the inflammation the bowels 
are loose, but towards its close the evacuations are but seldom 
made ; and when alvine discharges occur, they are often at- 
tended with great pain and force. The colour of the eva- 
cuations has been usually described by French physicians as 
green. But their colour varies ; sometimes it is brown, reddish 
clay-coloured ; influenced considerably by the colour of the food 
that is taken, which also imparts its consistency to it. No diges- 
tion taking place, the feces retain the appearance of the food 
when first taken into the stomach. From its resemblance to 
ordinary diarrhoea, at its first appearance it often excites little or 
no alarm, until sympathetic disturbance, or general constitutional 
symptoms arise. As the disease advances the skin becomes cold 
and wrinkled ; the face particularly, shows the effect of the suffer- 
ing the child experiences, and has a wrinkled and corrugated 
appearance, like that of an old person. The debility at this 
period is extreme, sometimes coming on with remarkable sud- 
denness : at other times the disease terminates in a profound 
stupor. 

No better summary of the symptoms, for the purpose of 



DIGESTIVE SYSTEM. 257 

diagnosis can be made, than that furnished by an analysis of 
eighty cases of enteritis, seen during life, and anatomically ex- 
amined by M. Billard. From these it appears that tympanitis, 
vomiting, and diarrhoea, are the most prominent signs of in- 
flammation of the mucous membrane of the small intestines. 
Inflammation of the large intestines, which he denominates 
colitis, is for the most part without vomiting or swelling of the 
bowels, but always attended with diarrhoea. This is what is 
usually termed dysentery ; and as it requires some considerable 
modification of treatment, will be the subject of separate re- 
marks. The absence, also, of febrile excitement is very com- 
mon in this disease, in young infants, and on this account we 
should not wait for the manifestation of any inordinate excite- 
ment of the blood-vessels, before we are led to suspect the 
existence of severe inflammation of the bowels ; for a fatal in- 
flammation may occur without any manifestation of it by the 
pulse. It is also of some importance to be able to distinguish 
inflammation from simple functional derangement ; in this there 
is often severe vomiting and purging, which may be arrested 
without hazard to the child. This condition may generally be 
ascertained by the absence of pain on pressure, and tenseness 
of the abdomen, which occurs more or less in every case 
of enteritis. The absence of heat will also distinguish the 
existence of functional derangement. 

Another diagnostic sign is in the lineaments of the face ; first 
pointed out by M. Jadelot, and contained in M. de Salle's edition 
of Underwood.* These are described by him as occurring 
more particularly in children advanced beyond the period of 
infancy. One of the most certain marks of abdominal affec- 
tions, according to M. Jadelot, is first the genal lineament, 
which extends from the commissure of the lips to the lower part 
of the face, where it loses itself; the second, the nasal linea- 
ment, extending from the inside of the alee of the nose, and 
surrounds the whole of the orbicularis oris muscle. These, as 
was before remarked, are not always to be seen in very young 
infants, yet some trait of them may be observed ; as a fold in 
the commissure of the lips, or outside of the orbicular muscle, 
corresponding with the nasal lineament. When the child suf- 
fers violent pain, there is a corrugation of the skin of the 
forehead ; and. indeed, the sudden appearance of wrinkles in 
any part of the face, almost always indicates the presence of 
abdominal pain, and demands the attention of the physician, 
for they are invariably marks of distress not to be overlooked. 
A pinched expression of face, without the presence of any par- 

* Trahe" des Mai. des Enfans de M. Underwood, etc., p. 36. 
33 



258 DISEASES OF CHILDREN. 

ticular lineament, in very young infants, is always a sign of 
gastro-intestinal inflammation. All these inflammatory affec- 
tions of the bowels may become chronic ; the thirst then is 
very great, the tongue much furred, and the appetite is much 
impaired, or is entirely lost ; the abdomen remains distended, 
while the rest of the body is much emaciated. The surface 
of the body is remarkably dry, and becomes of a dirty ash 
colour. The fever is remittent, and not violent in its cha- 
racter. 

Morbid Anatomy. — Dissections have shown, in some instan- 
ces, simple capilliform injections throughout the intestinal canal ; 
in others, there existed patches of redness, of greater or less 
extent, with tumefaction of the digestive tube, and friability of the 
mucous membrane. Blood has also been found effused in 
different portions of the intestines where there existed violent 
inflammation ; when this is the case, it is usual for it to appear 
in the stools during life. In more advanced stages, there are 
found patches or striae of a brown or slate colour, in the mucous 
membrane, indicating a chronic phlegmasia of the membrane. 

There has also been seen the altered condition of the 
secretion known as muguet, the disease which, when situated 
in the buccal mucous membrane, is called milk thrush. It has 
been described as a peculiar form of intestinal inflammation 
by some, while others maintain that muguet is in every instance 
essential to the disease. 

The muciparous follicles, the glands occupying the upper 
portion of the small intestines generally, and isolated in the 
ccecum and colon, sometimes become the seat of various altera- 
tions from inflammation. Sometimes they are red and tumefied, 
at other times, disorganized and ulcerated, giving to the ulcers 
in the intestines a peculiar appearance. 

The mucous membrane has also been seen in a state of dis- 
organization and softening, a condition entirely different from 
the white softening occurring in the same membrane during 
simple indigestion. This inflammatory softening arises where 
the mucous membrane has been long the seat of inflammation ; 
it at last becomes so altered in its structure as to retain few, if 
any, of its membranous characters, but is, on the contrary, a 
soft red mass. 

Some circumscribed spots of the mucous membrane have 
been found sphacelated, more particularly about the ileo-ccecal 
region. Eschars and adhesions, also, are very common in 
different portions of the intestines ; these generally arise after 
very violent inflammation. 

Such is the analysis of the various facts obtained from differ- 
ent sources. From these the French pathologists make four 



DIGESTIVE SYSTEM. 259 

varieties of enteritis, designating them as erythematic, follicular, 
with altered secretion, and with disorganization of tissue. 
Inasmuch, however, as there is great difficulty, if not impossibi- 
lity, in distinguishing them during life by any marked symptom, 
the distinction cannot be of much practical value in treating the 
disease. The violence of the symptoms may lead us to expect 
the termination of inflammation in the worst form, or disorgani- 
zation of tissue, and to proportion the activity of the treatment 
accordingly, or to make a prognosis of the case ; which, under 
these circumstances, must be unfavourable. 

All these varieties may occur simultaneously, and it appears 
to be a useless distinction to describe them as separate forms. 
In all an altered state of the secretion occurs, so that the form 
of muguet may be found more or less in every case. Indeed, 
so common is this state of the mucous membrane, that M. 
Valleix* is of opinion, that inflammation very rarely exists 
without the presence of muguet ; for of forty-six cases there 
were but three which appeared to present enteritis without mu- 
guet, on the simple uncomplicated erythematic enteritis. 

Treatment. — As in the disease just considered, it requires 
some judgment as to the abstraction of blood — a course by no 
means called for in every case of inflammation of the stomach 
or bowels. Indeed, the prostration is at times so great, as to ren- 
der the application of even a few leeches extremely hazardous ; 
and, in these affections, to cause their interdiction almost entirely 
in the Foundling Hospital at Paris. The cases found there 
are those of great debility, and are by no means guides for 
us, as I have repeatedly experienced. Still there is, perhaps, no 
inflammatory disease of infancy in wiiich there exists so much 
prostration as in those affecting the stomach and bowels. In 
children, however, somewhat advanced, when there is every 
evidence of acute inflammation, the use of leeches can by no 
means be dispensed with. But even in these cases the flow of 
blood should be carefully w r atched, as excessive prostration 
may ensue from the loss even of a moderate quantity of blood. 
In two instances I have met with very serious prostration, and 
nearly fatal from this cause; so that whenever there is a neces- 
sity of applying leeches to the epigastrium in children, I am par- 
ticularly cautious not to allow the blood to flow 7 until exhaustion 
is produced. Drs. Evanson and Maunsell advise a repetition 
of leeching, as preferable to allowing any continued loss of 
blood, which may greatly reduce the strength of the child 
without arresting the disease, and very judiciously advise the 



Op. Cit, p. 481 



260 DISEASES OF CHILDREN. 

physician himself to superintend the flow of blood, that it may 
be arrested when necessary. 

Fomentations, warm baths and blisters, are powerful means 
of combating enteritis. Counter irritation in some form should 
never be omitted. Fomentation ought to be substituted for the 
warm bath where the debility is great. So, also, in general, 
sinapisms may with safety be used in extreme debility ; they, 
as well as blisters, ought to be applied to the extremities. Si- 
napisms ought not to be kept long applied; as soon as a little 
redness and smarting are produced, they ought to be removed 
and re-applied, if necessary. Opium, in the form of Dover's 
powder, is a highly useful medicine in the treatment of enteritis, 
and should be used where the irritability of the stomach does 
not forbid its use. When this condition of the stomach exists, 
opium, as heretofore directed at page 197, will be found of great 
efficacy in allaying the extreme irritability of the bowels, and 
producing an action on the skin. Opium is of admirable benefit 
in inflammatory complaints of children, especially after bleeding, 
and was much in use by the older American practitioners. A 
reference to this subject has already been made in the article 
on pneumonia. 

It is not safe to have recourse to much internal remedies of 
any kind in this disease, except the opiates above mentioned, 
with gum syrup, or some other mild mucilaginous substance, 
taken cold. The child, if at the breast, should not, as is the 
custom in some foreign hospitals, be taken from the breast ; but 
if the milk be thought too irritating, it may be pressed from the 
breast and mixed with water before it is given to the child. 
M. Valleix, from the complete inefficiency of the means em- 
ployed in the treatment of some cases reported by him, which 
consisted chiefly of mucilages and feculent nourishment, is of 
opinion that a greater change of measures than is usually pur- 
sued, is clearly necessary for the successful treatment of ente- 
ritis: and refers to the measures adopted in the treatment of 
the affection in adults, as an evidence of the more successful 
method of managing the disease, observing that opiates are free- 
ly used in the latter, while a much greater change is made in 
their regimen. In children, on the contrary, but little change 
is made, and feculent substances are given in very large quan- 
tities, so that they are in fact kept suffering the whole time 
from indigestion,. 

It appears to have been a very common practice in the 
Foundling Hospital at Paris, to give gummed rice, or a thickened 
preparation of the same article, known by the name of " creme 
de riz," or salep, and other thick, feculent matter, for food to 
children, without making much if any change in these diseases. 



DIGESTIVE SYSTEM. 261 

M. Guillot has made it appear, by some very simple experi- 
ments, that young infants digest with great difficulty these fe- 
culent articles of food. In twelve children that died of differ- 
ent diseases, the feces found in the small and great intestines 
were subjected to the influence of the tincture of iodine, and a 
very intense blue colour was the result ; from which there could 
exist no doubt that a great portion of the fecula had passed 
through the whole of the intestinal canal without undergoing 
any change.* These are important facts, and in some respects 
account for the great mortality in the Hopital des Enfans 
Trouves, for they must constantly suffer from indigestion, and 
when affected with gastritis or enteritis, be exposed to the con- 
tinued irritation of unassimilable food. 

The bowels may be kept open by the means of enemata, 
composed simply of warm water, or castor oil mixed with an 
infusion of flax-seed. As costiveness is a very distressing and 
irritating condition of the bowels, it should be removed, and, if 
possible, by means of enemata. Tepid milk has been used as 
an enema in costiveness, and is a very efficient laxative. In 
no case should active purgatives be given ; but the most deci- 
ded advantage will at times arise, in protracted cases, from the 
use of a few grains of calomel and Dover's powder, followed 
by a little castor oil. Castor oil has been objected to as a ca- 
thartic in irritations and inflammations of the bowels, from its be- 
ing too irritating. These are contrary to my experience, and 
it has always appeared to me a mild cathartic, operating prompt- 
ly and with little or no griping, the alvine secretions being but 
little affected, while the contents of the bowels are freely eva- 
cuated. It is therefore particularly applicable to inflammatory 
diseases of the bowels, when it becomes necessary to procure 
evacuations from the bowels, which cannot be effected by- 
means of enemata. A very good combination is an emulsion 
containing mucilage. f For further details of the treatment, 
when diarrhoea is the most common symptom, the reader is re- 
ferred to the article on that subject. When the disease be- 
comes decidedly chronic, the mesenteric glands are likely to 
be affected and become indurated. Here it will be necessary to 
use more freely the hydrargyrum cum creta, and to rub the 
bowels with the ointment of iodine or hydriodate of potash. 



• Valleix, Op. Cit., 489. 
t ~fy 01. Rtcini, 3iij. — vi. 
Pulv. Acacise, q. s. 
Syrup. Simpl.,3ijss. M. 
ft. Emulsio. 
A dessert spoonful every hour, until it operates. 



262 DISEASES OP CHILDREN. 

The article on the mesenteric disease contains the details of 
the treatment which it will be necessary to pursue when these 
glands become enlarged. 

In protracted and chronic cases, it will sometimes be neces- 
sary to allay the irritable condition of the bowels, at other times 
to arrest the too copious discharges, and in some cases to sup- 
port the strength of the patient, by the use of tonics and bitters. 
All these varieties of treatment must depend on the judgment of 
the physician. The circumstances under which they are ap- 
plicable, are considered more at length under the article on 
diarrhoea, to which the reader is referred. 

DYSENTERY. 

Although this variety of intestinal inflammation offers but 
little if any dissimilarity in its appearance from that which it 
exhibits in the adult, and therefore scarcely to be regarded as a 
disease of childhood, yet, inasmuch as it is a very common 
affection of children in summer, and the symptoms exhibit some 
peculiarities distinct from inflammation in other parts of the 
intestinal tube, and as some difference of treatment is required, 
arising principally from the seat of the affection, it will be briefly 
considered with reference to its peculiarities. 

From the seat of the inflammation in the large intestines, it 
has of late been denominated colitis, as distinct from the inflam- 
mation seated in other parts of the intestines, which has re- 
ceived the name of ileitis. Both these diseases may exist to- 
gether, and severe gastritis may be also connected with them ; 
but nothing is more common than to see pure and uncompli- 
cated dysentery existing in childhood and infancy, entirely un- 
connected with inflammation in other parts of the intestinal tube. 

Etiology. — As this form of enteritis is more prevalent during 
the latter part of the summer and autumn, the sudden changes 
from extreme heat to the cold and damp of the night are un- 
questionably its most frequent causes. All the causes, also, 
which are the active agents in the production of other forms of 
inflammation in the mucous membrane of the intestinal tube, 
such as irritating and indigestible food, will be productive of this. 

Malaria, also, is unquestionably a very efficient agent in the 
developement of dysentery ; it is accordingly found to prevail 
as an epidemic in situations favourable to the existence of inter- 
mittent and remittent fevers, and it often exists simultaneously 
with them, or is observed to follow such affections. The re- 
markable connection of these diseases was long since observed 
by Sydenham ; and it is without question attributable to the in- 
fluence of this agent on the liver and portal circulation, which 
are considered more at length in other parts of this work. 



DIGESTIVE SYSTEM. 263 

Semeiology. — Dysentery usually commences with diarrhoea; 
the discharges at first being feculent and afterwards watery, 
with slight admixture of blood. They gradually change to 
mucus, in which there is more or less blood. There is but little 
fixed pain, but at times, immediately before a stool, a violent 
and very distressing tenesmus occurs. This is the ordinary 
character of the evacuations throughout the disease, with the 
occasional appearance of true feculent matter in the stools. 
When the disease is uncomplicated with inflammation in other 
parts of the mucous membrane, the regular and periodical 
evacuation of healthy feces will often take place, while the 
mucous and bloody discharges are continued during the inter- 
mediate periods. 

Fever, for the most part, attends this disease, although it is 
often but slight, and the pulse is a little quickened, although not 
much, if in any degree, increased in force. 

In very severe cases the fever is high and the tongue furred, 
while the local symptoms, tenesmus and mucous stools, are very 
frequent : the bowels continue costive, the alvine evacuations be- 
ing occasionally mixed with scybala. As the disease advances 
the anus becomes excessively painful and hot, and if relief be 
not afforded, great prostration of strength ensues, the pulse is 
feeble and the skin is cold ; distress and pain are experienced 
throughout the intestines ; nausea and vomiting supervene, and 
aphthae appear in the mouth. As in most abdominal diseases of 
children, coma and cerebral effusion are the most ordinary 
symptoms at the close. 

Dysentery is one of the most obstinate of all the diseases 
we have to encounter, and the favourable symptoms are often 
extremely fallacious, a chronic affection of the mucous mem- 
brane frequently following a protracted disease. From chronic 
dysentery recovery is very rare. 

Morbid Anatomy and Pathology. — Marks of inflammation 
are found in the mucous membrane of the colon and rectum — 
occasionally in the small intestines. These parts are also co- 
vered with shreds of inspissated mucus, or coagulable lymph, 
the thinner portions having been discharged by stool. Ulce- 
rations also exist in violent cases, while sphacelus is not uncom- 
mon under similar circumstances, especially if the case be 
protracted. In chronic cases there is some difference in the 
appearance of the mucous membrane, which is often mamilia- 
ted, looking as if cicatrization were in progress. 

Dysentery, therefore, in its early stage, is an inflammation 
of the mucous coat of the large intestines. This inflammation, 
spreading to the other coats, causes ulceration, and disorgani- 
zation of their tissues. At other times, the inflammation is 



264 DISEASES OF CHILDREN. 

chronic in its nature, more slow in its progress, and less destruc- 
tive to the parts affected. The division, therefore, of chronic 
and acute dysentery is well founded, and is of daily occurrence. 

Treatment. — The remarks as to the necessity of early 
blood-letting already given, when treating of gastritis and en- 
teritis, are applicable to the disease now under consideration, 
with this exception, that it may, in general, be more freely used 
than in inflammations of other portions of the digestive tube ; 
the prostration accompanying the disease not being so great as in 
either of the other affections. Leeches may be applied, in ileitis, 
to the anus ; but with far greater advantage in this disease. 
The free abstraction of blood in this manner is of decided advan- 
tage ; and in those cases where the blood flows freely in a sponta- 
neous manner, I have noticed much less tormina than in those 
cases where the evacuations consist principally of mucus. 
When leeches are applied to the anus, the bleeding ought es- 
pecially to be watched, as the hemorrhage may sometimes be 
excessive, from the extreme vascularity of the part; and great 
loss of blood, especially from capillary bleeding, has at times 
been fatal to young children. 

In dysentery, children bear the operation of mild purgatives 
far better than in other forms of enteritis. These, therefore, may 
occasionally be given, and castor oil, combined with a few drops 
of tincture of opium, will be the most suitable, from the mild- 
ness and efficiency of its operation. As the appending viscera 
are also simultaneously affected in many instances, and more es- 
pecially the liver, calomel, in small doses, when combined 
with Dover's powder, will be the proper means of exciting the 
biliary secretion, and relieving the congested state of the or- 
gan, and thus restore a freedom to the circulation of the abdo- 
minal viscera. 

Anodyne enemata are extremely useful in all degrees of 
tenesmus accompanying dysentery, but great caution should be 
observed in the quantity of laudanum used in the enema. The 
rule in the adult is to give treble the quantity which would be 
administered by the mouth. In very young children it is not 
uncommon to see complete stupor produced by the same quan- 
tity given by the anus which it is usual to administer by the 
mouth. It should therefore be cautiously given. Children ap- 
pear to be peculiarly susceptible to the action of opium ; and al- 
though a most decided advantage often follows the use of 
it in the peculiarly irritable condition of the system at this 
period of life, yet from the great rapidity of absorption, the 
smallest, quantity cannot be given without some hazard. Four 
drops of laudanum has killed a child a month old ; and in an- 
other, three drops given to a child of fourteen months, was fol- 



DIGESTIVE SYSTEM. 265 

lowed by coma, convulsions and death, in six hours. Dia- 
phoretics* may be more freely given in this than in the other 
forms of intestinal inflammation ; and in robust children, ad- 
vanced beyond the period of infancy, antimony will be admis- 
sible when the febrile action is high. But Dover's powder, 
from the peculiar action of its different ingredients, is admi- 
rably adapted to the treatment of dysentery. 

The disease often becomes exceedingly protracted, bearing 
some resemblance to severe diarrhoea! affections, with great 
prostration and exhaustion from the excessive mucous and 
bloody discharges. Astringents have been used in this con- 
dition with decided advantage. 

Various means of this kind have from time to time been em- 
ployed, and among them the acetate of lead in the dysentery of 
adults. This has also been used in cholera infantum, and the 
kindred diseases of children. For further observation on the use 
of astringents, the reader is referred to the articles on cholera 
infantum and diarrhoea. The subjoined vegetable astringents 
have been more especially used in the protracted form of 
dysentery of children, and the annexed formula is highly recom- 
mended by Dr. Zollickoffer, of Maryland, in the third volume 
of the New- York Medical and Physical Journal.* Dr. Cogs- 
well, of Washington county, New- York, when the disease 
prevailed very extensively among children, relied principally 
on vegetable astringents for the treatment of the disease in 
this form. These were composed of the white oak, Quercus 
alba, blackberry root, Rubus villosus, and the yarrow, Achillea 
millefolium, combined. They were boiled together in milk, or 
milk and water, which, when sweetened, was readily taken 
by children. No particular rule was observed as to the pro- 
portion of the ingredients, except that the oak and blackberry 
predominated. This course is represented to have been very 
successful in the epidemic dysentery, which prevailed some 
years ago in Washington county, in this state, f 

With respect to the diet and regimen of children labouring 
under dysentery, the same rules already laid down for them in 
other diseases of the bowels are applicable to this disease ; and 
the general principles of the treatment need not differ from 
that adopted in adults. A more particular detail, therefore, of 
what relates to the nature and management, is on this account 
deemed unnecessary in this work. 

* fy Euphorbiae Hyper. Fol. Excit., fss. 
Aquae Bullient. oj. 
ft. Inf. 
A large spoonful every hour, until the morbid symptoms cease, 
t N. Y. Med. Repos., vol. ii. p. 127. 
34 



266 DISEASES OF CHILDREN. 



PERITONITIS. 

The peritoneum is more commonly inflamed in young in- 
fants than is supposed, and many of the cases of abdominal in- 
flammation which have been referred to the intestines, have 
doubtless been of their investing membrane ; at least such would 
appear to be the case from the anatomical investigations of 
MM. Duges and Billard. 

Etiology. — Children have been born with every symptom 
of acute peritonitis, and its existence verified after death by 
the usual examinations. In other instances infants have been 
born feeble and emaciated, without exhibiting much evidence 
of disease, and after death, which usually with this affection 
takes place within a few hours, old and firm adhesions have 
been found between different convolutions of the intestines, and 
in the peritoneal cavity, which have doubtless been formed 
during intra-uterine existence. 

M. Duges gives a very interesting account of a case of acute 
peritonitis, which occurred at the Maternite, in a child prema- 
turely born, measuring about sixteen inches in length, and 
weighing between three and four pounds. It died in three 
hours after birth. On a post-mortem examination, all the usual 
appearances present in inflammation of this membrane were 
found.* In other instances infants have been born quite vigor- 
ous, and died a short time after birth, and the existence of peri- 
tonitis for the first time revealed on a post-mortem examination.! 
It is difficult to account for the origin of these cases of intra- 
uterine disease, which, from the firm and old adhesions existing, 
appear to have been of long standing, and to have passed through 
the various stages while the child was in utero. The mothers 
appear not to have had any disease of this nature, and, in gene- 
ral, were in perfect health. 

Peritonitis, like other inflammations, has its origin also in the 
usual causes of pyrexial diseases, and may attack children at 
all ages, as they are subject to the numerous exciting causes 
with which we are surrounded ; and irritation and inflammation 
of their organs are, from the greater susceptibility of their 
systems, much more liable to inflammatory action. 

Infants at the breast are not unfrequently attacked with this 
disease; but some anatomists have observed, that it appears to 
have arisen from a constipated condition of the bowels, or from 
some strangulation or obliteration of a portion of the intestinal 

* Recherches sur les Malad. les plus import, et les moins connues des Enf* 
Nouveau nCs; Paris, 1821. 
t Billard, Op. Cit. p. 353. 



DIGESTIVE SYSTEM. 267 

tube. It has also been remarked that mothers, suffering from 
puerperal peritonitis, do not impart it to their offspring. 

The disease also may arise as a sequel of others. 1 once 
knew a severe and fatal case of peritonitis, which suddenly su- 
pervened on the dropsy following scarlet fever, where the 
general symptoms were of so trifling a nature as scarcely to 
demand any attention. 

Semeiology. — In acute peritonitis the disease may be known 
without difficulty. The symptoms are severe pain in the ab- 
domen, which is increased on the slightest pressure. The ex- 
treme tenderness of the inflamed part makes the pressure of 
the ordinary cloths and bandages, and even the weight of the 
bed-clothes, insupportable ; while the abdomen is greatly dis- 
tended and tympanitic. The pain and tension are particular- 
ly severe around the umbilicus. With these symptoms there 
is also great restlessness, crying, and a peculiarly pinched and 
painful expression of the face. There are also eructations and 
vomiting, as the disease advances, and a constipated state of 
the bowels, continuing from the commencement. The pulse is 
small and frequent, and, indeed, even at the beginning, can 
scarcely at times be felt. 

If there should be any difficulty still in making a diagnosis 
of the disease from pleurisy with these symptoms, percussion 
of the thorax will be sufficient to establish it; a dull sound of 
the thorax being always present in inflammation of the pleura. 
This may be the more necessary, as dyspnoea is not a pathog- 
nomonic symptom of thoracic disease. Chronic peritonitis is 
much more difficult to ascertain ; the symptoms are slight, and 
easily confounded with those of enteritis, or chronic pleurisy. 

Peritonitis is one of the most fatal diseases of infancy, and 
its prognosis is decidedly unfavourable. 

Morbid Anatomy. — The usual signs of severe inflammation 
exist in every portion of the peritoneal cavity, as in the adult. 
Not only have these been found in that membrane, but all the 
abdominal viscera have been covered with concrete albumi- 
nous matter, by which the convolutions of the intestines were 
adherent. The surface of the liver, bladder, and all the abdo- 
minal and pelvic viscera, have also been coated with albuminous 
exudation ; while sero-membranous layers exist on the mesen- 
tery, and sero-purulent fluid is occasionally discovered in the 
cavity of the abdomen. 

Treatment. — The general principles of treatment of inflam- 
mation are applicable to this form of phlegmasia. The appli- 
cation of leeches to the integuments of the abdomen should 
be one of the first measures to be adopted, while the bleeding 
from the bites should be encouraged in the usual mode. The 



268 DISEASES OF CHILDREN. 

extreme feebleness of the circulation almost renders general 
blood-letting impossible in infants. In older children, it must by 
no means be neglected ; and although the pulse is often so ex- 
ceedingly small, and the surface of the body so cold as almost 
to forbid the use of the lancet, yet, as under similar circum- 
stances in adults, the pulse will in general show the effect of 
the increased circulation from the affected part towards the 
surface of the body, by an increase of its fulness. 

The warm bath is of undoubted efficacy, from the powerful 
revulsion it creates to the surface ; but what particular advan- 
tage can be derived from the marshmallow bath, as used in 
France, is difficult to understand. The application of flaxseed 
or marshmallows to the abdomen, is of use, from the length of 
time with which they may be applied ; and thus preserving a 
continued flow of fluids to the capillaries of the integuments. 
M. Chaussier, as quoted by Duges, recommends covering the 
surface of the abdomen with oil of camomile and oil of al- 
monds. It is difficult to comprehend for what purpose such a 
measure is recommended. Stimulating baths to the lower 
extremities ought to form a part of the treatment of this affec- 
tion, and every method employed to preserve an action on the 
surface of the body, especially in the extremities. 

Cathartics may safely be given in peritonitis, although, like 
most other remedies, often with very little effect on the disease 
in young infants. Calomel and ipecacuanha, from their effects in 
exciting copious secretion from the liver and intestinal mucous 
surface, and thus making a powerful revulsion, are an excellent 
combination when followed by other active cathartic mixtures, 
as infusion of senna, castor oil, etc. 

Antimony, James's powder, and other diaphoretic articles, 
may with more safety be administered in this disease, than in 
those affecting the intestinal mucous surface ; with the precau- 
tion necessary in the use of all such remedies, in cases of 
young infants, who are very easily, and not unfrequently fatally 
prostrated by the use of antimonial preparations. 

In convalescence, the usual precautions which are necessary 
in all abdominal inflammations, must be carefully employed in 
this disease, such as the application of flannel to the surface of 
the body, and the careful protection of the legs and arms from 
the cold ; for a return of the affection is very likely to ensue 
on any neglect of these measures. 

HERNLE. 

Children are liable to hernise from any of the natural open- 
ings of the body. Those occurring in the abdomen may arise 
not only from the natural openings, but also from some im- 



DIGESTIVE SYSTEM. 269 

perfection of the abdominal parietes. The latter are very rare, 
but the former are not unfrequent,and often arise from a natu- 
ral predisposition, for it is not unusual to see two children of a 
family thus affected. The most common of these is omphalo- 
cele or umbilical hernia. 

Umbilical hernia will therefore form the principal subject of 
these remarks. 

Etiology and Morbid Anatomy.— The cause of this affec- 
tion must be sought in the natural conformation of the part, 
and the relative condition of the intestines of the foetus and the 
umbilical opening. In the early period of foetal existence, al- 
most the whole of the intestines are contained in a sort of 
pouch at the base of the cord. As the foetus is developed, and 
the different parts assume their proper size and relative posi- 
tion, the convolutions of the intestines gradually recede within 
the abdominal cavity, while the opening which admits the 
cord closes, until at birth it is just sufficient to admit the um- 
bilical vessels. The base of the cord, however, will at times 
continue still large enough to retain a portion of the intestine, 
and a species of pouch is thus found to exist, formed by the 
skin and cellular tissue, and the peritoneum. A portion of the 
intestines, therefore, instead of returning within the cavity of 
the body, occupies the natural lodgment thus afforded ; and the 
constant pressure on the mass of the abdominal viscera by the 
abdominal muscles, assists in continuing them in this situation. 
The hernial sac for the most part contains a small part of 
intestine, but there have been found instances in which the 
liver, spleen, and a great portion of the small and great intes- 
tines have been found, as is the case in an instance mentioned 
by Scarpa.* When these large tumours exist, they appear to 
be connected with some other malformations about the abdo- 
men, or with an enlargement of the protruded viscera. But, 
besides this, a difficult labour may cause this condition to ex- 
ist, or at least, increase it ; for, according to Scarpa's experi- 
ence, the cases of enormous hernia occur in children that are 
born after difficult labours. 

Semeiology. — It is easily known by a tumour at the umbili- 
cus, soft and yielding, and always increased on crying or 
coughing. The tumour can, in most instances, be temporarily 
removed by gentle pressure. When the intestine is thus re- 
moved, a vacant place, well defined, is distinctly felt by the 
finger. 

When this hernia exists, it is generally evident from birth ; 
but in many cases it does not show itself until some days af- 

• Traits Practique des Hernies. Translated from the Italian by Cayol, p. 323;. 



270 



DISEASES OF CHILDREN. 



terwards, as the intestines do not protrude until they have been 
distended with food. 

Treatment. — Compression is the proper means of treating 
this affection ; that by ligature, formerly adopted, is generally 
disapproved of by modern surgeons : the rapidity with which 
the navel is closed, greatly facilitates the cure. These pro- 
tusions will continually occur for some weeks or even months 
after birth; but with a very gentle compression, aided by 
a bandage, a complete cure is soon effected, if nothing more 
than the intestine be protruded ; and even if it be for some 
time, even for years, neglected, the application of a proper 
truss, or even of a bandage, will almost certainly effect a cure. 

The object being to preserve the intestine within the abdo- 
men, the means of effecting it may be that which is best 
adapted to this end, without putting the child to any pain or 
inconvenience. For the most part a simple roller applied 
around the body, having in its centre, corresponding with the 
umbilicus, a graduated compress, is the best. This should be 
carefully applied, and will answer the purpose far better than 
any truss which can be procured ; for in general a truss is 
exceedingly difficult to keep properly applied to the abdomen 
of a young infant. 

Congenital inguinal hernia may also exist in young infants. 
It differs from all others, in the circumstance that the tunica 
vaginalis forms the hernial sac ; the portion of intestine form- 
ing the rupture being in immediate contact with it, arising from 
the non-adherence of the peritoneal canal, by which the testes 
have descended with the intestine ; in consequence of which, the 
protruded bowel and the testes lie together in the tunica vagi- 
nalis. In some cases the testicle has not descended, which 
should be first ascertained before any bandages are applied. 

It is to the genius of Haller,* Hunterf and Pott,J that we 
are indebted for our knowledge of the causes and morbid ana- 
tomy of this species of congenital hernia. For a further de- 
tail of its nature, these works, and those especially devoted to 
surgery, may be consulted. 

In some instances, this kind of hernia has taken place for the 
first time at the age of twelve or fifteen years. It has been 
supposed that in these cases the testes have remained until 
that period within the abdomen, and that the bowels accom- 
panied them in their descent. 



* Program. Herniarum. Observat., etc. ; Getting., 1749. 
t Medical Commentaries ; London, 1762. 

t Account of a Particular kind of Rupture, frequently attendant on New-born 
Children, etc. ; 1757. 



EXCERNENT SYSTEM. 271 

Semeiology. — To distinguish inguinal hernia is sometimes a 
matter of difficulty, as hydrocele is apt to be taken for it. In 
hydrocele, however, the scrotum is translucent; and, with a 
little care, the absence of the intestine may be detected. One 
of the principal sources of uncertainty is the increase of both 
tumours on coughing and crying ; and that the fluid, like the 
protruded bowel, may be returned to the abdomen. 

Treatment. — After the hernia is reduced, the same prin- 
ciple adopted in the management of all species of hernias is 
applicable to the present form. A temporary bandage, how- 
ever, is more suitable than a truss for young infants ; the lat- 
ter, however, may be used for older children, as in adults. 
The bandage and compresses should be frequently changed, as 
it is impossible to prevent the urine from soiling them, and 
causing inflammation and severe excoriations of the skin. This 
will almost certainly effect a cure, if the child be kept still, as 
the natural tendency during growth is to obliterate the opening 
through which the intestine has protruded. 



EXCERNENT SYSTEM. 

The term excernent is used as applicable to the two func- 
tions which are discharged by the secreting and absorbing ves- 
sels. It is a term used by Dr. Good, as best to express these 
two functions, which bear the same relation to each other as 
those of the arteries and veins. 

As the consideration of some of the various diseases of the 
different systems of necessity includes the excess or diminu- 
tion of glandular secretion, the present system will be limited 
to such as affect the lymphatics, and those organs whose office 
is the separation of excrementitious secretion, comprising the 
kidneys and the skin. 

PECULIARITIES OF THE EXCERNENT SYSTEM. 

Lymphatic System. — The lymphatic system is a part of 
great importance, but it was not until comparatively in recent 
times that its use was properly understood, although some 
parts of it were known to Galen and Eustachius. The organs 
which form the system of absorption are of two kinds, the 
lymphatic vessels and the lymphatic glands. The former, as 
is well known, perform the office of transmitting into the san- 
guineous system the fluids which are absorbed from the various 
surfaces of the body. They exist in two sets — the one super- 
ficial, the other deep seated ; but both anastomose very freely 
by plexuses. 



272 DISEASES OF CHILDREN. 

The form and arrangements of the commencement of the 
absorbent vessels, from their extremely minute size, are al- 
together unknown. Although detailed descriptions and draw- 
ings have been made of them as they appear on the internal 
surface of the intestines, and traced by the microscope to ori- 
ginate in the villi, or small projections that are attached to this 
part, yet the lymphatic absorbents have baffled the skill of mi- 
croscopic philosophers to detect their origin. 

The lymphatic glands occupy a large portion of the absor- 
bent system, connected with the lacteals and lymphatics. 
They are small bodies, of different forms and sizes, and situated 
singly or in groups in the course of the absorbent vessels; 
always more abundant about the joints, arm-pits, neck and me- 
sentery. These glands are very numerous in the mammalia. 
They are rare in birds, and still more rare in fishes. Although 
apparently essential to the proper transmission of the fluids, 
judging from their number, yet their use is unknown ; but what- 
ever be their use, they are evidently more important in the young, 
where nutrition is a process of great activity ; they are conse- 
quently found much larger, and contain a larger quantity* of 
fluid, than in advanced life. 

During infancy and childhood the activity of the absorbent 
system is surprisingly great, while the secretory function, and 
consequently the process of nutrition, are also in a state of high 
functional vigour ; these changes of interstitial removal and 
deposite being necessary during this period of growth. The 
action of this system declines as age approaches, and is very 
feeble in advanced age. The formation of fat is very abun- 
dant in young children, and in the foetus it appears in masses, 
unconnected with other portions. Thus, it is found between 
the muscles forming the cheeks, in the form of globular bodies, 
and gives to the cheeks of new-born infants the peculiar pro- 
minence which distinguishes the form of the face. The colour 
of the fat is much lighter in children than adults. 

The extreme activity of this system during childhood ren- 
ders it liable to diseases ; and affections of the lymphatic or- 
gans are strikingly peculiar to this period of life. Affections of 
this system at this time, illustrate, in a very remarkable man- 
ner, the principle of the predisposition to disease being often 
dependent on growth. 

The lymphatic glands differ in no respect from those of 
adults, except that their texture is softer and their size larger, 
and that in young children the lymphatic ganglia of the 
neck are more liable to be diseased than those of the mesen- 
tery ; although to this rule there are some exceptions, as I have 
seen. These glands are diseased in proportion to their deve- 



EXCERNENT SYSTEM. 273 

Jopement ; and those of the mesentery being but slightly deve- 
loped before the age of a year, are but little liable to be affected 
by disease. 

They are very remarkably under the influence of the atmo- 
sphere. When the climate or season is constantly cold and 
damp, and, especially, if added to this there is also great impu- 
rity from want of a sufficient ventilation, and if there exists also 
a deprivation of light, a complete assimilation of food cannot take 
place, and the developement of the body is imperfect. 

Like other fluids, that circulating through the lymphatics 
may be either in excess or deficiency, and thus affect this part 
of the body with all the consequences of a plethoric condition 
of the lymphatic system, or with the general want of vigour 
and tone arising from a defect of the important substances it 
conveys for nourishment and growth ; the former causing 
those peculiar inflammations which some individuals manifest, 
so different from the violent sanguineous action, turgescence 
and suppuration, w r ith which those abounding in blood usually 
present. The character of lymphatic turgescence, or inflamma- 
tion, partakes more of the nature of simple irritation in its 
general symptoms. So obscure are they, that they do not appear 
to be attended with any increased action ; but the deposition of 
albuminous matter, and the enlargement of the lymphatic 
glands, show the existence of this species of plethora. The 
opposite state of this system wili manifest itself particularly in 
a great loss of energy, and a defect in the general process of 
nutrition throughout the body. 

The lymphatic plethora will also impart to the blood a pecu- 
liar quality, known by the deficiency of red globules and fibrine, 
whereby the body is less capable of resisting the effects of cold, 
so that not only the glands themselves, as above stated, but the 
whole body, will be more susceptible to a lessened temperature. 
Thus, the lymphatic temperament, with its peculiar manifesta- 
tion in the ganglia, will be formed, and which, like other ulti- 
mate molecular conditions of the system, may be transmitted 
to posterity. 

The inflammation of the glands of the lymphatics is often 
excited by the irritation transmitted along their course. Be- 
sides this state of the mucous membrane in producing the 
mesenteric disease, the effect of insalubrious nourishment is also 
evident in the irritation excited in these glands by improper 
chyle formed from it. These, however, will be again brought to 
notice under the proper head. The effect of suitable nourish- 
ment in the production of lymphatic diseases is evident, not 
only in children who have arrived at the age when a variety of 
food is required, but it is also seen in sucking infants, who be- 

35 



274 DISEASES OF CHILDREN. 

come scrofulous if nursed, when first bom, by a woman who 
has been several months delivered. 

From the inspiration of impure air and the use of insufficient 
or improper food, the nourishment of the body is very materially 
influenced. If, therefore, a due supply of nourishment does not 
take place, the whole system must sutler, from the digestive to 
the nutritive functions. In some diseases the digestion, even of 
proper nourishment, is imperfectly performed. In others, al- 
though perfectly digested, yet when introduced into the absor- 
bent system, from some sluggish action in these vessels, arising 
from the causes already mentioned, and also from a hereditary 
transmission, the affections of these glands take place. In 
other instances, again, the influence of the deranged action is 
only evident in the process of deposition and nutrition, when the 
disease will be seated in the ultimate assimilating powers. 

One of the most striking evidences of a morbid state, and often 
in children without other marks of disease, is the arrest of the 
deposition of animal oil, and the consequent loss of plumpness 
of the body. In this instance, the action of the secernents ap- 
pears to sympathize with the diseased action in other parts and 
tissues of the body. 

In other instances the secernents themselves are in a state of 
morbid action, and, as in the case of rickets, there is a deficient 
supply of earthy matter, or of phosphoric acid, which are 
necessary for the formation of bone. In the growing condition 
of childhood, a full supply is needed, to effect a proper expan- 
sion of the body, and to continue and to maintain it in strength and 
firmness. This supply, when continued in a sufficient manner, 
preserves this part of the frame in its integrity ; but when in 
any degree defective, causes that condition of the system which 
so seriously affects the bones ; producing one of the most 
serious and lamentable diseases of childhood. The diseased 
action of the secernents is also apparent in dropsical affections, 
diabetes, and the numerous diseases of the skin. 

Cutaneous System. — The excretories of the skin form a very 
important outlet to the system ; and in endeavouring. to trace 
the lymphatics, it is evident that a great number of them have 
their origin near the cutis, absorption very readily taking place 
under circumstances favourable to this process. Works on 
general physiology contain numerous instances and experiments 
in proof of this power of the cutaneous vessels. 

The skin of the foetus, when first apparent, consists of a 
viscid coating, through which the immediate subjacent parts 
may be seen. It gradually increases in density until birth. 

The skin exhibits in infancy and childhood no wrinkles, in 
consequence of the quantity of fat beneath it ; when this is 



EXCERNENT SYSTEM. 275 

absorbed, the skin appears more in the form of folds than 
wrinkles. 

The exhalent vessels of the cutaneous system arc peculiarly 
delicate ; and when from any cause the cuticle is abraded by 
mechanical violence, or by heat, or other chemical action, they 
are immediately exposed to the action of the air, and are violently 
excited, and, in children, rarely escape inflammation ; resulting 
in the formation of purulent matter, or in the excessive action 
of the vessels themselves, pouring out a quantity of serous 
fluid. 

These excretory vessels are also remarkably controlled by 
the changes affecting the atmosphere, without any removal of 
their natural covering, being often chilled and rendered torpid 
by a sudden depression of atmospheric heat. They are also 
easily excited by irritations in the stomach and bowels, whether 
they are induced by inflammation, or simply by the presence of 
irritating food, exciting the mucous membrane. Urticaria is a 
familiar instance of the general sympathizing influence on the 
skin. 

Eruptive fevers, also, appear to direct their principal force 
on the excretories of the skin ; at least such is the opinion of 
some eminent physiologists and physicians ; but in one or two 
of these diseases, the whole capillary system would appear to 
be their seat, both within and outside of the body. 

The absorbents of the skin often become torpid in their 
action, by which only a portion of the fluid deposited is carried 
off; hence the deposition of more than can be removed, causing 
accumulations in the cutaneous follicles, whereby various pus- 
tular, and other eruptions are produced. 

The cutaneous secretions consist of what is denominated 
sebaceous matter, from the small glands above mentioned, which 
are situated in the tissue of the skin. These glands appear to 
have been in a very active state during foetal life, from the 
quantity of sebaceous matter which covers the child at birth. 

The circulation of the skin is very active in children, and 
especiaHy in young infants. The consequence of this excess 
of blood is the high vermilion hue so well known in children. 

This colour, however, does not exist before birth. As it 
receives, during intra-uterine life, only black blood, the skin 
undergoes a very remarkable change in its colour at the period 
of birth, from the red blood, which for the first time circulates 
through the body on the establishment of respiration. This is 
an important fact, as the colour indicates the condition of the 
respiratory system. 

This intense red colour rarely continues beyond the eighth 
day after birth ; from that time ^gradually diminishes, and dis- 



276 DISEASES OF CHILDREN. 

appears at an indefinite period. It is one of the strongest evi- 
dences of the health of the child. 

This abundance of fluids gives to the skin its plump, soft and 
elastic qualities, so different from the harsh and dry sensation 
which it imparts in old age. This softness continues for some 
time after birth, and the integuments can very easily be melted 
into jelly by ebullition. They arrive at their greatest density 
about the age of puberty. 

The skin, therefore, for the greatest period of growth, pos- 
sesses these marked peculiarities, and from abounding in all 
the requisites of developement, becomes thereby greatly pre- 
disposed to numerous diseases in its different tissues: a consti- 
tutional irritability peculiar to infants and children. The va- 
rious strophuli, and other inflammations of the skin, have their 
origin in the sanguineous turgescence and state of high excita- 
bility of the skin in children. 

During intra-uterine life, the animal sensibility of the skin, it 
is supposed, does not exist ; but after birth, it is, on the contrary, 
very great. Its high vital properties render it extremely sus- 
ceptible to the impressions of surrounding objects. The water 
used in washing the child, the clothes, and even the stimulating 
effect of the atmosphere, communicate a great degree of exci- 
tation. 

All infants present at the time of birth much the same colour 
of the integuments : but about the third month the peculiar hue 
of the child becomes evident, and the dark complexioned can 
then be distinguished from the pale and ruddy. The peculiar 
complexion of children is greatly under the influence of external 
causes : temperature and exposure, as well as the peculiarities 
of constitution, cause great variations in whole tribes of people. 
The reticulated tissue is that on which the natural colour of 
the skin depends, and these alterations are caused by some 
unexplained change in the blood, which circulates in it in great 
abundance. Its mucous or fatty consistence has caused a 
doubt as to the propriety of terming it a distinct coat or texture ; 
but whatever be its nature, it is the proper colouring portion of 
the skin; it therefore differs greatly in different races of men, 
and often differs in the same individual in different parts of the 
body, causing the various spots or moles observed on the skin 
of children and adults. In some it is absent, or rather from a 
defective secretion of the rete muscosum, or from an imperfect 
elaboration of it when secreted, it imparts a peculiar dead 
white hue to the skin, forming the disease called albinism. 

Haller mentions the existence of spotted infants, and also of 
instances of black children being born of white parents, and 
white children whose parents were black. 



EXCERNENT SYSTEM. 277 

The mottled appearance of the arms, a violet, mingled with 
white and red, although it would appear to arise from an im- 
pediment in the local circulation, is generally regarded as an 
evidence of health; those that are plump, and whose limbs are 
large and full, are such as exhibit this hue when their limbs are 
exposed to the influence of a slight depression of temperature. 

Sometimes the skin has exhibited at birth various kinds of 
excrescences in different parts of the body ; they are generally 
those of a prolongation of the integuments, or the marks known 
by the name of noevi materni, which appear to be the first 
stage of these cutaneous excrescences advancing towards in- 
flammation. Other coloured spots are the simple alteration of 
the cutaneous pigment. 

Some authors have described the birth of children whose 
face, body and limbs were covered with hair, and which have 
been mistaken for wild beasts, and were on this account de- 
prived in ancient times of their legal rights as children.* This 
condition is simply the continuance of hair, which covers the 
foetus in the early part of intra-uterine life. Perhaps it was 
the persistence of these hairs on the faces of infants, which has 
been described as a beard. f 

Among the most common phenomena in infants, is the 
healthy separation of the epidermis, described by Orfila, 
Thierrey, and Billard. It occurs after birth, and only in mature 
children. 

This separation of the cuticle commences at uncertain pe- 
riods ; but generally not before the second or third day alter 
birth ; it is usually at its height on the third or fifth day. The 
duration of this process, also, is very variable ; it having con- 
tinued even as long as two months. 

The cause of this process has been explained to be from 
the transition the child experiences from immersion in the 
waters of the amnios, by which the skin is kept moist. On ex- 
posure to the air it becomes dried, and the cutis then cracks 
and dies ; separating in scales, plates, lines or powder, accord- 
ing to the part of the body from which it exfoliates. 

From the extreme activity of the absorbent system in chil- 
dren, and the like exaltation of the functions of secretion and de- 
position which have been noticed, it is evident that the process 
of nutrition and composition, of repairing and building up, is 
very great during the time of life allotted to growth. At this 
period, arterial action, so necessary to the proper performance 
of the secretory function, predominates over the venous ; this 
arterial predominance is evident to the eye throughout the 

♦ Haller, Opera. Minora., Lib. i. t Eph. Nat. Cur. Dec. ii., Case 1C3. 



278 DISEASES OP CHILDREN. 

entire cutaneous surface ; and anatomical investigations show 
the same throughout every part of the infant frame. The 
nerves, also, of organic life, are in a state of high activity ; for 
on a harmony of action of the sanguineous vessels which 
supply the requisite nourishment, and of the nerves which 
control the nutritive process, depend the proper and healthy 
deposition of materials for the growth of the body. In this 
process the absorbent system largely enters, and on the undis- 
turbed harmony of these, the preservation of the body, in its 
healthy condition, depends; while, during the process of deve- 
lopement, the nutritious or depositing function must be in excess. 
At the time, therefore, when those changes occur, which are 
necessary to the increase of the body, and where there already 
naturaiiy exists a difference in the various powers, a great dis- 
turbance of this mutual action must ensue, when any circum- 
stance arises to interfere with the harmony of action. Conges- 
tion or inflammation, both sudden and violent, usually follows 
an interruption of the harmony of action attending the process 
nutrition. 

From the activity of the nervous system, also, at this time, 
by which a healthy vigour and a uniform deposition of mate- 
rials of growth is preserved, by the universal sympathy of the 
body with the action of its different parts, arise also those 
sudden derangements in distant parts, and especially in those 
where this nervous influence is in high activity, for the growth 
more particularly of a part, as the brain in children. This 
sympathetic action is observed in man at all ages, but far more 
sudden in its invasion, active in its progress, and fatal in its 
results in the infant. 

The actions connected with nutrition and growth, occur in the 
parenchyma of the different organs in the internal and external 
tissues of the body, and in vessels themselves, on which growth 
depends, in every tissue. During the developement of the 
foetal body, the effect of deranged action in the formative pro- 
cess is evident in the various malformations of the child. After 
the completion of the body, and on the establishment of inde- 
pendent life, malformations rarely occur, but the body is sub- 
ject to the various laws which are observed to control it in the 
adult, and similar diseases are excited into action by causes 
which produce them during the different periods of life. But 
how much more frequent and violent they are during child- 
hood, is familiar to every observer ; arising from a predisposi- 
tion acting also during the progress of disease. The natural 
and necessary harmony of action is thus completely deranged; 
and the diseases of childhood, when once excited, are remarka- 
ble for their violence, and demand a corresponding prompt- 
ness in their treatment. 



EXCEJINEXT SYSTEM. 279 



SIGNS OF DISEASE FROM THE EXCERNENT SYSTEM. 

The lymphatic organs exhibit few appearances indicative of 
disease when considered by themselves, independently of their 
effects in controlling the developement of the body generally, 
or of some particular portions. These are, therefore, more 
properly considered under other diseases, as the effects of a de- 
ranged action are often more manifested in other parts than in 
the lymphatic system itself. 

The peculiar state where the lymphatic temperament predo- 
minates, is manifested by the leucopathic condition of the whole 
body. The process of secretion appears to be very active in 
some parts, while the absorption of the fluids is not in the same 
state of activity ; hence the fulness of the cellular tissue takes 
place, particularly in the abdomen, and children with this pre- 
dominance exhibit an unusual protuberance of this part of the 
body. 

The skin in this temperament is pale, the muscles are soft, and 
the circulation is slow — the pulse being soft and weak. 

The vital force is but languid, and any disturbance of its ac- 
tion is attended with but little inflammatory action of an acute 
kind. 

The enlargement of the lymphatic glands about the neck not 
unfrequently arises from tinea capitis, and appears to be the 
effect both of a transmitted inflammation along the course of 
the absorbent vessels, and of the absorption of the imperfect 
secretion in the scalp. 

The swelling of these glands also arises in the hereditary 
disease denominated scrofula, and is an evidence of the ten- 
dency of the system to chronic inflammation in the different 
absorbent ganglia throughout the system. 

When these tumours persist for a long time, and become of a 
livid or purple red, they are unquestionably of a scrofulous 
nature. 

These latter tumours rarely appear before the second year, 
and seldom continue after the seventh. In other instances, 
however, the disease does not make its appearance till after the 
seventh, and for the most part disappears about the fourteenth 
year. 

The cutaneous system furnishes many indications of disease 
arising from its size, consistence, contractility, colour, sensibili- 
ty, and from the existence of inflammatory eruptions. 

The size or volume of the integuments depends on the con- 
dition of the sub-cutaneous tissue, being much increased in 
hyperemia of the part, which is very common in eruptive 



280 DISEASES OP CHILDREN. 

fevers, especially in scarlet fever. It also arises from the pre- 
sence of fat or serum, and invariably attends local inflamma- 
tion in a greater or less degree. 

The volume of the integuments of the face is not increased 
in acute abdominal diseases, except when they are complicated 
with congestions about the brain ; it therefore yields a good 
diagnostic sign in diseases of children, where this complication 
so often occurs in the progress of their disease. 

A swelling behind the ear, which terminates in suppuration, 
gives favourable prognosis in diseases during the period of den- 
tition, but is more particularly favourable in exanthematous 
affections. In acute exanthematous disease, there is always a 
congestion about the head ; and a swollen condition of the inte- 
guments of the face always accompanies this state of the head. 

The presence of fat may easily be recognised by the uniform 
volume of the body, and the elasticity of the skin. (Edema- 
tous swelling may be known by the pitting of the integuments 
on pressure, and the shining appearance of the whole surface. 

These swellings occur after scarlatina, measles and erysi- 
pelas, but more frequently succeed the first mentioned disease. 
Infiltration of the cellular tissue, occurring as a sequel of these 
diseases, is not of so serious a nature as the same swellings 
arising from other causes ; the former being simply an effect of 
local inflammation, the latter more often the result of derange- 
ments or malformations in the centre of the circulation. 

A diminution of the size of the integuments in chronic 
diseases, especially in affections of the mesenteric glands, is an 
unfavourable sign ; when occurring in acute diseases, the prog- 
nosis is not so unfavourable. 

An increase of the consistence of the skin takes place with 
an increase of its volume. The skin of the face, and especially 
of the forehead, is tense and shining in hydrocephalus. This 
tenseness will arise from the serous infiltration of the cellular 
tissue, and is the disease known in Europe as the skin-bound, 
or induration of the cellular tissue. 

The temperature of the skin is very great in all fevers and 
inflammations, and is particularly marked in scarlet fever. In 
inflammations of the bowels the heat of the abdominal integu- 
ments is also great ; and, in general, the heat of any particular 
portion of the integuments indicates an inflammation in the parts 
beneath. 

The colour of the skin depends on the state of the vascular 
system in young children. In those that are older, emotions of 
the mind, as in adults, produce changes in its colour, showing 
the influence of the nervous system on the remote circulation. 



EXCERNENT SYSTEM. 281 

A leucopathic state of the skin depends on the excess of 
serum in the blood, and indicates the preponderance of the lym- 
phatic temperament. The change of the skin in eruptive fevers 
to white, is a very unfavourable symptom ; so is also this colour 
in the congested variety of scarlet fever, when often no eruption 
appears until after death. 

A general redness of the skin is its natural colour in infants — 
a local redness is a sign of cutaneous inflammation, and also of 
inflammation in the subjacent organs : as in the case of such an 
affection of the brain, the skin of the face exhibits an excess of 
blood. Alternate paleness and redness of the face denotes the 
inflammatory condition of the meninges, which terminates in 
hydrocephalus. 

The blue colour of the skin arises from some disturbance in 
the circulatory and respiratory apparatus. A preternatural 
fulness of the small veins of the skin appears to be its immediate 
cause. 

All causes which prevent the oxygenation of the blood, as 
such diseases of the heart as interfere with the proper transmis- 
sion of venous blood to the lungs, will cause a blueness of the 
integuments. It is, therefore, usually an indication of the persist- 
ence of the foramen ovale, although this has been at times found 
to exist on a post-mortem examination, while the alteration in 
the colour of the integuments has not existed. The prognosis 
is decidedly bad if it be connected with an impediment in the 
respiration, which cannot be remedied. 

An ashy or earthy colour of the skin occurs in protracted 
diseases of the bowels, and especially in cholera infantum, and 
in all diseases connected with a chronic disturbance of the 
chylopoetic viscera and defect of nutrition. 

The yellow colour of the integuments arises from ab- 
sorption of the bile, from congestion of the liver, and obstructions 
in the bile ducts, arising from various causes, but in children 
more particularly from worms. 

The jaundice of children is a much more favourable disease 
than that occurring in adults, as in the latter it for the most 
part occurs in organic changes of the liver. The orange 
colour of the skin in new-born infants may arise either from 
bile received into the blood-vessels, or from a peculiar yellowness 
of the serum. The former may be known by the adnata of 
the eyes partaking of the general tinge of the body; when it 
arises from a simple yellow colouring of the serum, the eyes 
remain unaffected. A yellow colour of the skin in young in- 
fants, connected with a disease of the stomach and brain, is much 
more unfavourable than when not thus complicated. 

The skin is usually more dry in the first stage of all acute 

36 



282 DISEASES OF CHILDREN. 

diseases, but more especially in inflammation of the bowels ; 
and if this dry state continue long, the prognosis is rather 
unfavourable, but not so much so as in adults ; and, in general, 
the excretion of the skin does not, in young children, yield so 
satisfactory a prognosis as in those that are older. Local 
sweats, especially when occurring about the head, are unfavour- 
able during acute disease. 

Copious sweat often occurs after the disappearance of a 
convulsive paroxysm in children; it is not then to be regarded 
as critical, for a recurrence of the convulsions often takes place 
after a free sweat. 

The natural odour of the sweat is acid, but not so marked in 
children as in adults ; in the miliary eruption it is more evident. 
In affections of the skin the sweat assumes a peculiar odour. 
In porrigo it has the smell of cat's urine ; in scabies an empy- 
reumatic odour prevails ; in protracted pityriasis it has a 
mouldy smell, and small-pox gives an odour resembling fish brine. 

The diagnosis of cutaneous eruptions will more properly be 
considered under the heads of the respective cutaneous diseases. 
Eruptions generally, which occur after the continuance of 
acute or chronic diseases, give a favourable prognosis. 

Herpetic eruptions are usually connected with diseases of 
the stomach and liver. Herpes labialis is a critical eruption in 
all inflammatory and febrile diseases. 

Pemphigus is generally an indication of gastric affection ; 
and the species denominated gangrenosa infantalis, is a sign of 
great debility, and gives an unfavourable prognosis. 

The regular course of the eruption in scarlatina and rubeola 
is to be regarded as giving a favourable prognosis, when not 
accompanied with severe complications of some internal organs. 
Its disappearance is to be regarded in an unfavourable light. 

Erythematous eruptions, when not caused by any direct 
application to the skin, are signs of acute or chronic disease of 
the intestinal tube. Ecthyma occurs as a critical eruption in 
acute intestinal diseases. Porrigo fovosa is a sign of a scrofu- 
lous habit. 

The sensibility of the skin is either exalted or diminished in 
diseases. The alterations in the ordinary sensations of the 
skin, such as tickling, itching and prickling, occur in the affections 
of the skin, at the orifices of the mucous membranes, and are 
usually the signs of irritation in the gastro-intestinal mucous 
membrane, either from inflammation or the presence of worms; 
if at the rectum, of the existence of the oxyures. 

These sensations, when existing on the surface of the body, 
and when accompanying an acute excitement of the blood- 
vessels, indicate the occurrence of an exanthematous eruption. 



EXCERNEN'T SYSTEM. 283 

DISEASES OF THE EXCERNENT SYSTEM. 
SCROFULA. 

Scrofula has, from the remotest periods of which we have 
any records, received a particular attention from physicians, 
and appears to have been a disease of more universal preva- 
lence than almost any other. Among the moderns, it has been 
the subject of a number of essays in Europe, where it is much 
more prevalent than in the United States. Morgagni, Wise- 
man, Carmichael, Fothergill, and others, have all directed their 
attention to this highly interesting subject. It would be vain 
to enumerate all the writers on scrofula which have appeared 
within the last half century ; a few of the most prominent will 
suffice. 'The work of Hamilton, on scrofulous affections, con- 
tains many valuable practical suggestions.* One of the best, 
probably, that has appeared, is by Hufeland; first published in 
1795. This work has been translated into English, and is a 
valuable addition to our stock of professional literature, f 
Baumes and Baudelocque, in France, and Lloyd, in England, 
have also published excellent monographs of the disease. J 

Struma or scrofula appears under two forms ; one. where 
the disease is confined to the lymphatic glands alone, and is 
purely a local affection. In this variety it appears as tumours, 
generally ending in ulceration ; situated chiefly about the neck, 
and is the affection known as the king's evil.|| The other form 
is, where the disease has become a constitutional affection, and 

♦Observations on Scrofulous Affections, etc., by Robert Hamilton, M. D. ; 
London, 1791. 

t A Treatise on the Scrofulous Disease, by C. G. Hufeland, Physician to the 
King of Prussia, etc. Translated by Charles D. Meigs, M. D. ; Philad., 1829. 

t Mem. sur le Traitement dela Malad. ScrofuL, etc. Sur le Virus Scrophuleux, 
Paris, 1805, par F. Baumes. Treatise on the Nature and Treatment of Scrof., 
etc., by Eusebius Arthur Lloyd ; Lond., 1821. 

II The name king's evil is derived from the supposed virtue in the royal 
touch, for the cure of this disease. Edward the Confessor was the first who 
touched invalids suffering with it, and it is said he received this special privilege 
from heaven ; and the same power was attributed to all his lineal descendants. 
Ancient authors consider the virtue possessed by the king, as referable to his 
sanctity and not to his royalty. It would appear, therefore, that there exists a very 
good reason for the absence of this power in some of his posterity. During the 
reign of Charles the Second, the practice of resorting to the royal touch was at its 
height; and multitudes flocked to receive the benefit of the royal remedy. The 
number of persons touched by him in twenty-four years, was 92.107. The news- 
papers of that period announced the event, and the ceremonies attending it, and 
detail the particulars on one occasion, where GOO persons were touched. Cromwell 
afterwards tried, in vain, to exercise this royal prerogative. 

The practice continued even to the time of Queen Ann; and Dr. Johnson, 
when a child, was taken to be touched for the scrofula, by the advice of the cele- 
brated Sir John Floyer. The third volume of the Edin.'Med. and Surg. Journ. 
contains a very interesting account of the practice of " touching for the evil." 



284 DISEASES OP CHILDREN. 

shows itself in different parts of the system, in the well-known 
diseases of phthisis, rickets, and the various affections arising 
from a scrofulous diathesis, and appearing in almost every 
tissue and organ of the body. 

The first mentioned form, as a disease particularly of the 
lymphatic system, is that which is the subject of the present 
remarks. 

In former days the term scrofula was applied to the tumours 
existing in the parts already mentioned, and characterized by the 
peculiar marks of the disease. The description given of them 
by the Roman disciples of Hippocrates, corresponds exactly 
with the disease as it appears at the present time.* From the 
accounts we have, neither the Greek nor Roman writers appear 
to have regarded the disease as a constitutional affection, al- 
though phthisis, and other diseases depending on a scrofulous 
diathesis, unquestionably existed. 

Etiology. — Scrofula was long supposed, and the idea con- 
tinued even to a very recent period, to be contagious ; but 
every attempt to propagate it by inoculation, and by exposing 
those in health to its influence, by placing them in the same bed 
with scrofulous patients, has failed. It is, therefore, satis- 
factorily proved, that it does not arise from a specific virus. 

The predisposition to scrofula without doubt exists in some 
individuals by inheritance from their parents. This hereditary 
transmission consists rather of such a natural arrangement in 
the ultimate molecules constituting the structure of the body, as 
to dispose it to a peculiar set of actions, whereby one class of 
functions naturally tends to certain modifications in their per- 
formance, than in the transmission of any peculiar taint in the 
body, as is the case in syphilis or small-pox. A constitutional 
peculiarity and predisposition to the disease, therefore, descends 
from the parent to the child. It does not, however, follow from 
this that all the children of a scrofulous parent are necessarily 
affected with scrofula, or manifest that peculiarity which is 
denominated a scrofulous diathesis ; for they may pass through 
an entire life without any appearance of the disease, from the 
absence of an exciting cause, and may even transmit the predis- 
position to their offspring, without being affected with the disease 
in any other than a latent form. 

* Struma quoque est tumor, in quo subter concreta quaedam ex pure et san- 
guine quasi glanduioe oriuntur : quae vel prajcipue fatigare medicos solent, quoniam 
et febres movent, nee unquam facile maturescunt; et sive ferro, sine medicamentis 
curantur, plerumque iterum juxta cicatrices ipsas resurgunt ; multoque post medi- 
camenta ssepius ; quibus id quoque accedit, quod longo spatio detinent. Nas- 
cuntur maxime in cervice ; sed etiam in alis, et inguinibus, et in lateribus. Celsus, 
Lib. v. xxviii. — 7. 



EXCEENENT SYSTEM. 285 

The hereditary predisposition may be illustrated by the con- 
figuration of the external parts of the body, by which children 
so often bear a striking resemblance to their parents. If this 
be so in the visible parts of the frame, it may likewise exist in 
other parts which are concealed from direct observation. The 
molecular conformation of the body in its several parts, being, 
therefore, transmissible to the offspring, the action of these parts 
will undergo certain modifications dependent on the organiza- 
tion, and from this cause children will be subject to the diseases 
with which their parents are affected. 

In children, where the disease is hereditary, the constitution 
exhibits externally a peculiar appearance, and this diathesis 
may be known where there exist i a softness and flaccidity of 
the flesh, light hair and blue eyes, florid cheeks and a smooth 
skin. Children with this scrofulous tendency often have a 
large and tumid upper lip. 

Although at every period of life the disease may be developed, 
yet unquestionably childhood is the time when the predispo- 
sition to the local disease is the greatest ; in addition to this, 
scrofulous affections of the eyes and bones are most likely to 
occur also at this period. After puberty the lungs become 
more often the seat of this peculiar affection than before that 
period ; and there is nothing that so clearly exhibits the influ- 
ence of growth in developing certain diseases, as the change in 
the liability to disease manifested in the absorbent and lym- 
phatic system. 

This predisposition is not hereditary in every instance, for 
numerous causes may arise to produce a morbid change in 
the action of the lymphatic system, and thus give rise to the 
disease; this, it is evident, must have at some time been the 
case, even in hereditary diseases. It may therefore be acquired 
by the action of the same causes which develope it in those 
subjects who are predisposed to the disease. This important 
fact illustrates, in a remarkable manner, the pathology of the 
disease, which will be considered hereafter. 

Among the most common exciting causes, is the influence of 
a cold and humid climate. The effects of climate are of 
familiar observation ; and the change from a cold, wet country, to 
a warm and dry region, upon those who suffer from the various 
forms of a scrofulous habit, is well known, producing alterations 
which no medicine can effect, while the change from a warm 
climate to a cold, damp country, will cause the developement of 
scrofulous affections, as has been observed to occur in the youthful 
inhabitants of the East and West Indies, on their removal to a 
colder region. The variable weather so often occurring in 
the winters of temperate climates, is a fruitful source of the 



2286 DISEASES QF CHILDREN. 

disease, especially when, as is always the case, this valuation 
is accompanied with great humidity of the air ; and it is more 
common to find it in these climates, or in those elevated situa- 
tions of hot climates which expose them to sudden atmospheric 
changes, than in those countries where a uniform cold is main- 
tained from the commencement of winter until its close. The 
cold is subject to but little vicissitudes in the winter in the 
northern sections of the state of New- York, the New-England 
States, and Canada, and the disease consequently is less preva- 
lent than in other portions more subjected to alterations in 
temperature. 

The effect of this cold and humid atmosphere is not only in 
the obvious influence it produces on the disturbance of the 
capillary circulation of the surface, but also by its constant 
action on the extensive respiratory surface, by which an irrita- 
tion is maintained in the lungs, whereby an imperfect change 
is effected in the blood — a change interfering with the nutritive 
process ; for the proper performance of which a full alteration in 
the blood should be produced. Such would, indeed, be expected 
to be the case, where the disease exists primarily in that part 
of the system which forms so important an office in the com- 
position of the body as the lymphatic. 

But in addition to this cause, there exists another, having a 
close analogy to the former ; and this is the deterioration of 
the atmosphere, from the crowding together of a number of 
inhabitants in large towns and manufactories. It is well 
known how much more prevalent this disease is, in all its 
forms, in towns and cities, than in the pure air of the country ; 
and every one is familiar with the distressing consequences 
manifested in the different scrofulous affections in the town of 
Manchester, in England, a number of years since, as recorded 
by Dr. Percival.* The whole number of deaths from scrofu- 
lous cases, as mentioned by him, was about one third of the 
entire number of deaths among the children of that place. 
In the hospital for sick children, at Paris, one half of the bodies 
that were opened exhibited marks of scrofula in some part of 
the body. Dr. Alison has conclusively established this fact, by 
carefully comparing the relative mortality from this cause, 
among children in the pure air of a country parish in Scotland, 
and that of the manufacturing town above mentioned. f The 
bad effects of impure air on the tender and susceptible frame 
of children, I have frequently had occasion to observe, and 
have often noticed that it is far more injurious of itself than 

* PercivaPs Works, vol. iii. p. 107. 

t On Path, of Scrof. Dis., Trans. Medico-Chirurg. Soc, Edin., vol. i. p. 383. 



EXCERNENT SYSTEM* 287 

improper diet in older children ; the latter, although unques- 
tionably a great cause of diseases, may yet be rendered diges- 
tible by habit ; and an entire change of food, at first difficult 
of digestion, may become suitable for the child, and be easily 
digested. These remarks apply more especially to the forma- 
tion of the constitutional predisposition. 

This agent is so evidently a cause of scrofula, that Baude- 
locque has given as his opinion, that it is perhaps the only cause 
of the disease ; and Sir James Clark considers it as a more 
powerful agent in the destruction of human life among chil- 
dren living in workhouses, where we have seen that scrofula 
prevails, than impoverished diet.* 

In accordance with this are the facts mentioned by Mr. 
Carmichael, of Dublin, in his account of the scrofulous disease 
which prevailed in the House of Industry in that city, where 
one hundred and fourteen children were lodged in one ward, 
the air of which became insupportable in the morning, while 
hundreds were confined in the school-room during the day ; 
the disease prevailed under these circumstances in all its fatal 
violence. The effects of impure air, even on the foetus, in in- 
terfering with the nutritive process, is evident in the remarkable 
fact mentioned in the London Medical Gazette, of the year 1832, 
that monstrous births are not unfrequent in the gloomy dun- 
geons of Lille. The influence of light on the developement 
of ova, has been shown by Edwards in experiments on those of 
tadpoles, the regular process of which is materially affected by 
a deprivation of this agent.f 

It is here proper to remark, that scrofula is by no means so 
prevalent in this country as in Europe. The same causes de- 
veloping a different morbid condition of the system, and affect- 
ing chiefly the chylopoetic viscera. From the influence of 
climate a diarrhoea is often the result of confinement to an im- 
pure atmosphere ; as was recently the case among the pauper 
children of this city, where a severe and fatal affection of the 
bowels prevailed, arising from the badly ventilated condition 
of the building on Long Island, in which they were lodged. 

To this cause may also be added that of bad food, which, 
when united to those already mentioned, will invariably pro- 
duce a diathesis favourable to the formation of some form of 
scrofulous affections. Imperfectly elaborated milk will also 
dispose the sucking infant to scrofula ; and Wiseman mentions 
that a child nursing from a scrofulous nurse, will have the dis- 
ease developed. Whatever differences of opinion there may 

* Clark on Consump. and Scrofula, p. 233. 

t Influence des Agens Physiques sur le vie, p. 398. 



288 DISEASES OF CHILDREN. 

be as to its precise pathology, it unquestionably, when first de- 
veloped, owes its origin to those causes which produce an altera- 
tion in the nutrition of the system ; and therefore we find that the 
combined influence of a cold, wet atmosphere, a confined and 
ill-ventilated residence, and an insufficient diet, are the prin- 
cipal incidental causes of the disease ; and when a union of 
these circumstances is found, strumous diseases prevail more 
extensively than where any two of them alone are present. 
These have been more especially pointed out in an excellent 
monograph by Baudelocque, published in 1833. 

Local injuries have also, in children predisposed to it, exci- 
ted it into activity ; so also has small-pox, measles or hoop- 
ing-cough, and any protracted disease which acts on the gene- 
ral system, as the other causes above stated, by impairing the 
energies of the body, and thus affecting the process of nu- 
trition. 

Semeiology. — The disease shows itself in the lymphatic 
glands, principally of the neck, in children, about the third year, 
or from this period until puberty ; after this it seldom appears 
in this form. 

Tumours appear not only on the side of the neck and behind 
the ears, but under the chin and in the arm-pits. They are at 
first moveable, and of an oval or globular form, and a little elas- 
tic to the touch. They are at first without pain and discolour- 
ation of the skin ; in this state they may continue for a long time, 
and will even acquire a large size, without any suppuration or ul- 
ceration, but will be removed by absorption. This, however, 
is not the usual course of these scrofulous tumours. The skin, 
for the most part, assumes a reddish or purplish hue, when their 
consistence undergoes a change ; from being slightly elastic, 
they are now soft, with a feeling of fluctuation in some parts of 
the enlarged gland ; for this softness, and the ulceration which 
follows, are by no means uniform throughout the diseased part. 
The skin over the softened portion becomes thin and pale, and 
at length small openings form, giving passage to a kind of puru- 
lent matter, at first of a yellowish colour, and curdy consist- 
ence. These openings unite, and the discharge changes to a 
fluid resembling whey. These ulcerated tumours gradually sub- 
side, but others arise near them, passing through the same 
stages of tumefaction, softening and ulceration. At other times 
the ulceration proceeds, and a sore, very tedious and unma- 
nageable in its nature, is the result, discharging a sanious fluid, 
mixed with curdy flakes. This ulceration sometimes heals 
partially, while the discharge continues in another portion, and 
fresh tumours, which also degenerate into ulcers, form in their 
vicinity. This irregularity in the ulcerative process, partial 



EXCERNENT SYSTEM. 289 

healing, and the formation of new tumours and ulcers, give to 
the affected part, when healed, a very unsightly, and even, at 
times, deformed appearance, from the irregularity of the cica- 
trices, and the deep scars, crossed by bands and wrinkles, 
and the puckered form of the skin. 

Morbid Anatomy and Pathology. — The different stages of 
the enlarged glands of scrofula exhibit different appearances 
in the texture of the morbid part. Thus, Dr. Abercrombie 
states that they exhibit, in the first stage, when cut, an uniform 
fleshy texture, of a pale flesh colour, and soft consistence. This 
colour becomes paler and the texture softer. The glands then 
undergo a change in these particulars in different portions, for 
some parts lose their flesh colour, and appear somewhat trans- 
parent, while the texture has the appearance and consistence 
of cartilage. Alterations are also at the same time observed, 
from the natural colour to the peculiar white, which is the last 
stage of morbid alterations, and in every respect analogous to 
the white tubercle in the lungs. 

The irregular progress of the disease is manifested in the 
existence, at times, of all these changes at once, observable in 
different parts, of large masses of the disease. In the most ad- 
vanced stage, the white, opaque, ash-coloured, tubercular mat- 
ter abounds the most, and is afterwards softened into the well- 
known cheesy and ill-conditioned suppuration.* 

The pathology of scrofula has been the source of much dis- 
cussion, but the opinions appear to have settled down to the 
inflammatory nature of the disease, in all its forms, whether of 
glandular enlargement or the formations of tubercle. With 
respect to the glandular or local affection, which is the form of 
the disease now under consideration, it would seem, in some 
instances, to be a simple congestion of the gland at first, by the 
lymph flowing through the vessels, and which afterwards ex- 
cites, by its mechanical distension, the inflammatory action with 
which the glands are affected. At other times the inflammation 
appears to be coeval with the existence of the tumours, and from 
the commencement identified with the disease ; under both 
circumstances it is evidently a modified inflammation, as we 
see it here, although in some forms it appears to be destitute 
of all other characters of inflammation than that of tumefaction. 
The opinions of several writers are that it is always a disease of 
debility, and dependent on debilitating causes.f Dr. Good ap- 
pears inclined to this opinion, and quotes Garn and Richter.J 

* Abercrombie on the Nature and Origin of Tubercular Diseases. Trans, of 
the Medico-Chirurg. Soc, Edinb., vol. i. p. 685. 
+ Armstrong on Acute and Chronic Diseases, vol. ii. p. 101. 
t Study of Medicine, vol. iii. p. 221. 

37 



290 DISEASES OF CHILDREN. 

By far the greatest number, however, adopt the opposite view. 
Broussais,* in France, Alison,f in Great Britain, Gross,J Paine,|| 
and others, in the United States, all identifying tubercle with 
the disease before us, and regarding it as dependent on one 
and the same cause. It was formerly supposed that an acidity 
of the humours was present in scrofula; and that an altered 
state of the lymphatic fluid, in some respects, existed, has been 
the opinion in almost every country. Hufeland's views are, 
that the disease consists of debility, with a specific irritation of 
the lymphatic system, and a peculiar alteration of the lymph. 
This scrofulous acrimony, as he terms it, he considers as the 
alterations produced in the lymph, by the altered action of the 
lymphatic glands, whereby the assimilation is not properly 
effected, and an imperfect fluid is the result, which becomes a 
source of irritation to the glands. § A change in the fluid is not 
incompatible with the opinion of the congestive or inflammatory 
nature of the disease. 

The difference of opinion which has prevailed as to the 
nature of scrofula, may admit of some explanation when the 
various causes which are known to modify the same disease 
are considered. Among them may be mentioned climate, and 
an imperfect developement of the diathesis, which it is well 
known determines the tendency of inflammation in the forma- 
tion of scrofulous diseases. 

The difference in the type is what is observed in all diseases, 
in different countries, and probably there is no disease which 
presents the same uniform character in all ; as climate influences 
the developement of diseases, so it will also exert a modifying 
effect on the disease when formed. The differences thus 
arising, are the only way to account for the discrepancies of 
existing opinion as to the nature of the same disease. This is 
remarkably illustrated in measles and scarlet fever, which in 
some countries and in certain seasons appear scarcely to require 
any remedy ; while under other circumstances they may be 
violently inflammatory, or be attended with great prostration. 
We need but refer to past records to be satisfied of this fact, 
and of the great benefits arising from the use of remedies at 
one time, which at others have been discarded, from having 
been found decidedly hurtful. In the scrofulous diseases of 
children the same condition may, and doubtless does exist; 
and the continual exposure to the causes already mentioned, 

* A Treatise on Physiology, p. 470. 

t Trans, of the Med. Chirurg. Soc, Edinb., 1824. 

t Path. Anatomy, vol. i. 1834. 

II Med. Comment., vol. ii. p. 608. 

§ Op. Cit., p. 63. 



EXCERNENT SYSTEM. 291 

but more particularly to the effects of impure air in closely 
confined and crowded habitations and manufactories, may 
control the actions of the system, so as to prevent the develope- 
ment of a true inflammatory action; while it is easily conceived, 
that in those cases where a predisposition exists in subjects 
removing from a warm to a cold climate, and the disease for 
the first time excited by the action of the latter cause, scrofula 
may exist in a state of active inflammation. 

An imperfect developement of diathesis, which determines 
the character of the inflammation in scrofulous habits, or, per- 
haps, as it may be better expressed, the proportion of normal 
action still maintained in the system, will impart to the diseased 
action a character more or less allied to diseases in organs 
which have undergone but little alteration from their normal 
state. 

This leads to the consideration of the predisposing cause of 
scrofula, which must be sought for in the nutritive process, 
whether the alterations in the composition of the body during 
the time of growth have been hereditary or acquired ; for we 
must go back to the ultimate state of interstitial action, in order 
to obtain some idea of the pathology of scrofula, as it appears 
in the different organs, depending, as it clearly does, on the 
imperfect action of the nutritive process. This view of the 
departure from the healthy state of the organs, will present 
the subject, if not in a form perfectly satisfactory, yet in some 
degree approximating to the truth, as it will exhibit the disease 
in question as depending on that important part of the nutritious 
function, the lymphatic system, so actively engaged during the 
period of growth. 

That which strikes the observer, when considering scro- 
fula as manifested in the remote tissues, is the peculiar 
phenomena which arise on the application of the ordinary 
exciting causes of inflammation. A chronic inflammatory action 
ensues in some of the tissues, with characteristic symptoms, 
producing a disease remarkable for its obstinacy ; while in 
others, tubercles form, giving rise, when in the lungs, to phthisis. 

The phenomena are so different from those of inflammation 
occurring in an individual not possessing the scrofulous diathe- 
sis, as at once to arrest the attention of the inquirer, and direct 
it to some change in the original composition of the affected 
part, by which a very marked alteration is produced ; if it 
were otherwise, the phenomena would be such as are usually 
observed in properly elaborated tissues. It must, therefore, be 
dependent on the nutritive process — on the deposition of ulti- 
mate molecules during the growth of the body, in some degree 
destitute of the proper proportions which are necessary to form 
the part in its normal state. 



292 DISEASES OF CHILDREN* 

This, as we have already seen, may be hereditary or acquired ; 
in both instances depending on the supply of healthy materials 
in the blood, which is the agent employed in the nutrition of 
the body. The blood being composed of the constituents of 
the chyle and lymph, must necessarily be affected with any 
changes which may occur in them, and thus affect the con- 
dition of the various parts of the animal frame. 

The absence of this disposition may usually be known by the 
existence of the sanguine temperament. The blood abounds 
in fibrine, the complexion is dark or ruddy, the muscles firm and 
well marked ; those, on the contrary, that possess the diathesis, 
which leads to the formation of tubercles, exhibit a softness of 
the muscles, possess a light or delicate red complexion ; the red 
particles of the blood and the fibrine being deficient, while 
lymph and albuminous matter abound. All this impoverished 
state of the fluids arises from the causes already mentioned as 
productive of scrofula; and the preponderance of the lymphatic 
system will naturally create a lymphatic plethora. 

It appears, therefore, to be connected with the active state of 
the lymphatic vessels, as there is in scrofula a manifest excess of 
albumen, chemical analysis having detected a large proportion 
in lymph. 

Although there is still needed a much more extended set of 
experiments on the subject of lymph than has yet been made, 
to render our knowledge in its change, either in quality or quan- 
tity, more satisfactory, yet abundant evidence exists that it is in 
greater quantity in time of youth. Haller has shown that the 
lymphatic glands contain a larger proportion of fluid in the 
young than in the adult.* Mascagni also states, that these 
glands are more turgid with lymph at this period of life.f A 
larger quantity also exists after a long fast. 

If an abundance of lymph exists, the blood must be surcharged 
with albuminous materials, and a deficiency of fibrine prevails; 
from this cause an imperfect composition of the body must 
ensue, which is thereby predisposed to take on a peculiar diseased 
action, on the application of an exciting cause of disease. This 
is seen to exist constitutionally in phthisis and rickets. The 
last mentioned disease exhibits, in a very evident manner, the 
effects of imperfect nutrition ; for during the process of growth 
a remarkable change occurs in a healthy subject in the consis- 
tence of bones* while in those individual s suffering under the pecu- 
liarities of constitution caused by scrofula, the bones are often 
defectively nourished, and their developsment does not corres- 
pond with the developement of the body generally. The 

• El. of Physiology, vol. ii. p. 325. t Vas. Lymph, pt. 1, sect. 5, p. 33. 



EXCBRNENT SYSTEM. 293 

tubercular disease, on the contrary, does not exhibit similar 
marked effects from growth with imperfect nutrition, for the 
soft parts undergo but little change from growth, but are formed 
with much the same elements as they afterwards possess. 

The consideration, however, of constitutional struma, is 
foreign to the object of the present chapter ; but the diseases 
of a general character, w T hich more especially affect children, 
and which are modified by a scrofulous constitution, will be 
treated of under their respective heads. The subject has been 
merely alluded to as in connection with the action of the absor- 
bent system, the important agent in moulding the body during 
growth. There can be no question, as is remarked by J. Hunter, 
that the nutrition of the body is supplied principally by the 
chyle, and that the office of the absorbent system is to preserve 
the symmetry of the body, w T hile nutrition from this source is 
but a secondary function. 

If, from any cause, the latter function is more than ordinarily 
and permanently excited, either by the hereditary constitutional 
peculiarity, or by the continual use of insufficient and improper 
food, which acts not only in supplying the blood with imperfect 
chyle, and thus directly affecting the process of nutrition, but 
likewise by exciting the action of the absorbent system to 
supply the defective nourishment, whereby an undue quantity 
of albumen is conveyed to the blood, an alteration of nutrition 
would ensue. 

The most severe and violent forms of constitutional stru- 
mous affections are connected with impure air. The blood 
thus deprived of the salutary change it undergoes when expo- 
sed to the influence of oxygen, interstitial nutrition is directly 
effected. When, however, inappropriate food is used by chil- 
dren, the effect appears to be more direct on the lymphatic 
system ; but in all its forms an undue supply of albumen to the 
blood exists, showing an increased supply of materials through 
the lymphatic vessels. 

The local effects of a deranged action of this system, in the 
production of the chronic irritation, and enlargement of the 
glands of the neck, axilla, etc., and known as scrofula, or the 
king's evil, is the disease more especially considered. 

This affection is not to be confounded with that occurring in 
the glands, arising from the transmission of the inflammation 
along the course of the lymphatics, and traceable by a red line 
or streak, which, for the most part, is painful to the touch. This 
not unfrequently occurs in inflammation of the skin, tinea capi- 
tis, etc. When the glands are inflamed from this cause, they 
are rapid in their swelling, hard and painful to the touch, and 
terminate by the formation of a true pus. Such inflammations 
are likely to occur in those of a sanguine temperament. 



294 DISEASES OP CHILDREN. 

In such as possess the scrofulous diathesis or lymphatic tem- 
perament, an entirely different condition of the gland occurs ; 
the symptoms of which have already been described. In this 
form, a true suppuration never takes place, but the termination 
shows a condition differing from a sanguineous inflammation. 
This form of disease is described by M. Broussais as a sub- 
inflammation. If by this is meant, an inflammation produced by 
the white blood or lymph, and corresponding in this respect with 
what is usually known as inflammation, produced by the agency 
of the red, fibrinous blood, the designation is correct. But it is 
evident that the term is very liable to be misunderstood ; for 
there is not at first, essentially, a real inflammation in the irrita- 
ted and enlarged glands, although it usually occurs in the 
course of the disease, and may at times appear so early, as to 
be almost simultaneous with the tumefaction of the gland ; for 
it may inflame, and also be congested, with albuminous fluid 
contained in them ; if it occur afterwards, it is produced by the 
mechanical pressure of the part. 

The fluid conveyed through the lymphatics, in a healthy 
state of the part, is arrested in the glands, and there undergoes 
some change, as appears from experiments made by M scagni ; 
for the lymph entering into them differs from that which passes 
out. # They therefore appear to form some important part in 
nutrition ; but in what this consists it is impossible to ascertain ; 
that it is important, is evident from the large size of these glands 
in children and youth, when nutrition proceeds rapidly, and the 
action of the lymphatic vessels is great, from the necessity of 
the continued changes in the dimensions of all the parts of the 
body. This is a very striking illustration of the principle, that 
growth is a great predisposing cause of disease. 

Here, then, we have, at an early period of life, a greater action 
of these glands; and from the laws of physiology, the more an 
organ is exercised, the more is it predisposed to disordered 
action, and from their necessary incessant performance of their 
function is found their liability to disease. 

What is the irritation which first causes a stasis of the lym- 
phatic fluid in the gland is impossible to say ; very little, if any- 
thing, is known with respect to the normal action of these parts, 
and much less of the departure from it. That a congestion of 
lymph occurs is evident from the fact, that sometimes when 
these glands yield a fluctating feeling on pressure, and from the 
supposition that pus exists, an opening is made, nothing will flow 
but a little blood and lymph, and in a short time lymph alone will 



♦ M: scagni. Loc. Cit. 



EXCERNENT SYSTEM. 295 

ooze from the wound. It may be supposed that some^irritating 
qualities exist in the lymph itself, as it owes its origin to all the 
varying parts of the body ; for although in appearance the same, 
yet close examination has detected a difference in lymph flowing 
from different parts ; and it is also an important fact to re- 
member, that while the lacteals possess an elective property, 
and only convey chyle, the lymphatics will take up anything 
that is presented to them, both such as are extraneous to the 
body, and such as form the varied parts of the body itself, both 
solid and fluid. Besides those different actions of these two 
sets of vessels, another property they possess might also tend 
to produce an alteration in the fluids of the one and not in the 
other. It is the difference in their respective functions : the one 
simply conveys the nutritious fluid already prepared, the other 
elaborates what it removes ; hence an altered and morbid con- 
dition may exist from the imperfect action of the vessels them- 
selves. 

In the first stage, therefore, the disease is always caused by 
a simple lymphatic congestion of the part, and is variously 
modified with regard to the accompanying inflammation, by the 
peculiar constitution of the patient and the influence of climate. 
While in some places it has been regarded as a disease alto- 
gether oi debility, in others it has, in every instance, been con- 
sidered as one of inflammation, more or less acute. It can 
easily be conceived, that among children suffering from the 
combined effects of bad air and impoverished diet, insufficient 
also in quantity, a degree of debility must ensue, which would 
altogether forbid the employment of depleting measures ; while 
such as have not been thus exposed will retain a different 
amount of vigour, materially controlling the disease when 
formed. 

The disease in some is one of a purely lymphatic congestive 
character, for a long time exhibiting no pain on pressure, and 
exhibiting neither heat nor discolouration of the skin even in 
such as do not possess a marked deficiency of stamina ; the 
inflammatory stage, however, is always sure to make its ap- 
pearance before suppuration ensues. In others this inflamma- 
tion will quickly appear on the enlargement of the gland ; this 
occurs when the lymphatic temperament is but slightly de- 
veloped, where any irritation will readily excite inflammatory 
action. This accumulation of lymph imparts to the suppurated 
gland its imperfect character, as regards the pus secreted, which 
possesses but little resemblance to properly formed pus, being a 
thin fluid, mingled with curdy matter. 

Treatment. — The principles of the treatment have varied 
at different times, according to the existing ideas of the nature 



296 DISEASES OF CHILDREN. 

of the disease. The supposed presence of acids in the fluids 
has led to the employment of alkalies. Narcotics and sedatives 
have also been much used, doubtless also from the irritation 
caused, as was believed, by the acrimonious nature of the lymph, 
while the actual benefit arising from their use may be referred 
to allaying the irritability of the system generally, and thereby, 
in some instances, affording nature an opportunity of returning 
to the normal exercise of her functions. The doctrines which 
have more recently prevailed, have induced some physicians 
to consider it exclusively, and under all circumstances, as in- 
flammatory, and they have consequently been induced to use 
local antiphlogistic measures, and to rely solely on the local 
abstraction of blood for the treatment of scrofulous tumours. 
The judicious physician will not adopt either mode to the ex- 
clusion of others, but will suit the remedy to the condition of 
the existing case. 

According to the views of the nature of the disease above 
stated, the treatment naturally divides itself into, 1st, hygeinic ; 
2dly, general; 3dly, local. 

As the disease depends on the abnormal action of the 
absorbent system, a function of the greatest importance during 
the period of childhood, a time of active nutrition and growth, 
we may reasonably look for a natural tendency of the system 
to the normal exercise of its functions, as the period of demand 
gradually ceases. This may often be effectually anticipated 
by a judicious application of the rules of hygeine. 

The food ought to be nutritious, and in every respect suited 
to the condition of the patient. It seldom happens that we see 
the disease in such a form as to require a decidedly tonic and 
highly nutritious diet, but a proper supply of nourishment is 
absolutely necessary to the healthy action of the nutritive pro- 
cess. Wine and malt liquors, so much recommended formerly, 
are rarely, if ever, required for this disease in the United States. 

In connection with appropriate diet, there is nothing so bene- 
ficial as free exercise in the open air ; nothing indeed can com- 
pensate for the want, of this. Where it is used, children seldom 
suffer from scrofula; and the natural exercises of running, leap- 
ing, etc., so incessant among children, keep their absorbent 
and capillary system in full activity, and distribute the tone 
and vigour thus induced over the whole frame. The effects 
of active bodily exercise in imparting the signs of the proper 
supply of red fibrous blood, is evident in all persons whose 
employments lead them much in the open air; and among such 
of the ancients whose education was founded in a great degree 
on gymnastics, scrofula was but little known. 

For the same reason, those children who are disposed to 



EXCERNENT SYSTEM. 297 

scrofulous diseases ought to be guarded in the too early use of 
their intellectual faculties, especially in learning long lessons 
at school. Their tasks ought to be short, and followed bj 
some amusing occupation. They should not be subjected to 
severe punishments, but every method ought to be taken to 
invigorate the system, by rendering their necessary studies as 
much a pleasure as possible. 

It will also be necessary to pay particular attention to the 
sleeping apartments of children, a subject often receiving less 
attention than almost any other hygeinic regulations of children. 
They, for the most part, pass the greater part of their time in 
them ; and a close attention to ventilation, and a proper choice 
of their situation, where the latter can be made, is of vast im- 
portance ; not only in the management of the disease before 
us, but also in all affections of children. Mattresses form the 
best bed for them ; the accumulation of heat, and of the 
miasms which are disengaged from the body during the night, 
do not so easily take place on a hard surface as in a mass of 
feathers, where their escape is almost impossible : the relax- 
ation from these causes, as well as from the excessive perspi- 
ration, will produce a debility greatly affecting the functions of 
the absorbent system. If it be possible, the bedroom of chil- 
dren ought to be in an upper story, with windows so arranged 
as to allow of a free ventilation. The habitation, also, should, 
if it be in a low and humid situation, be removed to a dry and 
warm place. 

All these details, it may be said, are impossible to have properly 
attended to ; but much may be done in the prevention of diseases 
in children, by procuring a free circulation of air. 

While these precautions are used, the body ought to be kept 
well protected with suitable clothing. The variations of tem- 
perature produce the most serious consequences; and the use 
of woollen garments in winter, and suitable protection from 
sudden changes at every season, should form a part of the 
hygeinic measures. 

In connection with these measures, frictions are very impor- 
tant agents in the management of weakly children ; they have 
a direct effect on the sanguinary capillaries, and also excite the 
radicles of the absorbents, whereby circulation through the lym- 
phatics is promoted. These may be performed by means of a 
soft flesh brush, or a piece of flannel or dry sponge, three or four 
times a day. 

An entire removal may, in severe cases, become necessary ; 
and a residence near the sea, in the summer months, will be an 
efficacious means of invigorating the system, where the ex- 
hausting summers destroy the energies of the system. In short, 

38 



298 



DISEASES OF CHILDREN. 



every rational means of improving the general health will be 
needed in the prevention and cure of scrofula. 

The application of pharmaceutical agents may be either 
general or local ; and the general principles of science will be 
our guide in their use generally, even in such as appear to par- 
take in some degree of the nature of specifics. 

When commencing the treatment of this disease, the con- 
dition of the primse vise should be examined, and if evidences 
of derangement be found to exist, the treatment should be com- 
menced by restoring the secretory functions of the chylopoetic 
viscera. For this purpose purgatives must be employed. The 
use of resinous cathartics, Hufeland remarks, is more important 
than is generally supposed ; and where there is a want of tone 
in the stomach and bowels, with a tendency to constipation, 
jalap he has found the most useful of purgatives ; besides its 
influence in relieving the bowels of their load of mucous secre- 
tion, an impression appears to be exerted on the lymphatic 
system. Mild purgatives have but little effect on the indolent 
engorgements of children. He gives it in doses of from four 
to six grains, to children two or three months old, combined 
with a little magnesia. It appears to be much more safe to 
give it in smaller doses, in the proportion of six to fifteen grains, 
for children from three to six years. When an addition to its 
purgative qualities is needed, any of the neutral salts, or the 
bi-tartrate of potash, may be combined with it, or it may be 
combined with calomel. The addition of oil of lemon will 
correct its nauseous taste, and it may be rubbed up with a 
little sugar.* The resin of jalap is a good purgative, and may 
be given in an emulsion, rubbed up with sugar or with almonds. 

Aloes is another of this kind of purgative medicine, which 
will be found very efficacious in the treatment of this disease, 
when attended with much derangement of the abdominal vis- 
cera, as it combines a tonic property with its cathartic qualities. 
Wherever, therefore, there exists a loss of appetite and a 
general debility, aloes will be a useful article for the correction 
of the disordered action of the bowels, and to impart, at the 
same time, tone to the stomach. Aloes, combined with rhubarb, 
has been long a favourite purgative with the German physicians ; 
and where the object is to procure a free evacuation without 
the loss of strength, which often attends a copious action of 
the bowels, these substances are of great value.f 



* fy. Pulv. Rad. Jalapae, gr. xv. 

Hydr. Subm., gr. iij. 

Oleo. Sacch. Citr., 3j. M. 
For a child eight years of age. 



t ~fy Pulv. Rhei., gr. iij. 
Potass. Bitart., gr. vi. 
Oleo. Sacchar. Macid., 3ss. M. 
ft. Pulv. dent. tal. dosi., No. vi. 
One to be given thrice a day. 



EXCERNENT SYSTEM. 



299 



While speaking of the necessity of attending to the state of 
the primae vias, it will be the proper place to allude to alkalies 
and antacids in general, which have been so much in use in 
the treatment of this disorder, and the benefit of which has been 
so abundantly demonstrated by experience. Lloyd is very 
partial to antacids, particularly soda ; and without reference 
to any acid condition of the lymph, it is a sufficient indication 
of their necessity when there exists evidences of acidity in 
the stomach; for the digestive process is, under such circum- 
stances, very materially deranged, and the nutritive functions 
also more or less disturbed. 

They have been for a long time in use, and were supposed not 
only to destroy the acid of the stomach, and thus remove one 
of the exciting causes of scrofula, by improving the functions 
of digestive organs, but also by exerting an action on the lymph 
in correcting the acid which it contains. Any of the alkalies 
or absorbent earths may be employed for fulfilling the above 
indication, according to the condition of the bowels ; if they 
need to be moved, soda or potash may be combined with the 
cathartic medicine already mentioned.* If a simple correction 
of acidity is all that is needed, they may be given alonef or 
combined with some mucilage,J or if there exist no evidence 
of gastric inflammation, and a mild stimulant appears to be 
needed, combined with some aromatic infusion. || The bi-car- 
bonate of potash has been particularly recommended in scro- 
fulous affections by Richter and others. Where there is a 
decidedly debilitated condition of the system generally, needing 
tonics and bitter infusion, the Colombo root will be found the 
best, as it is an excellent stomachic with but little stimulating 
qualities, and does not astringe the bowels ; it may be given in 
the dose of a tablespoonful of the infusion of the pharmaco- 
poeias, either alone or combined with some alkali and aromatic 
confection. 

Dr. Hamilton advises small portions of mercury or antimony, 



* R- Rad. Rhei, 3j — 3ij. 

Digere per hor. c. 

Aq. Fervid., |j. 
in colat. solve, 

Potass. Bi-carb., 3j. 

Syrup. Aurantii, oSS. M. 

Sit. Mistura. 
A tablespoonful three or four times a 
day, to a child three or four years of age. 
t Ri Potass. Bi-carb., 3ss. 

Aquse Destill., §iss. 

Solve. 
A teaspoonful three or four times a day. 



t R< Potass. Bi-carb., gr. x. 
Mist. Acaciee, 5j. 
Vitell. Ovi, No. ij. 
Aquae Font., giij. 
Syrup. Simpl., 3j. M. 
ft. Emulsio. 
Dose, a dessertspoonful three or four 
times a day. 

II R; Aqua Foeniculi , gvi. 

Potassee Bi-carb., 3ij. 

Syrupi, gj. M. 
A dessertspoonful occasionally. 



DISEASES OP CHILDREN. 

or both combined, in very small doses ; or of neutral salts dis- 
solved in water. The former of these he recommends for 
infants and the latter for children, especially towards the age of 
puberty. He decidedly prefers the " neglected remedy of the 
polycrest salt." His practice was to administer an aloetic pill 
at night, and the sulphate of potash in the morning, continuing 
this practice for several weeks. After the bowels had been 
freely acted on, he then commenced with chalybeate prepara- 
tions, but without discontinuing the use of the neutral salt. 

The general remedies for scrofula, which have been consi- 
dered almost as specifics, are all of a tonic and stimulating 
nature, and are therefore only applicable to the stage of simple 
engorgement without inflammation. Whenever, therefore, there 
is pain on pressing the tumours, or a slight febrile action, these 
should not be used, but the treatment must be conducted on the 
general principles of combating inflammation and fever, but 
particularly by attention to the condition of the stomach and 
bowels. 

Mercury has long been an efficacious remedy in the treat- 
ment* of scrofula, and under the circumstances just mentioned, 
may very advantageously take the place of other remedies of 
a general nature. It is evidently a very powerful exciter of 
the lymphatic system, while it augments the whole secretory 
functions. It is, therefore, useful in cases where there exists 
febrile reaction, and when the fever is great should be com- 
bined with antimony ; and it is to this stage alone that its use 
should be confined. In those cases where there is great irrita- 
bility, it should be carefully avoided, and in protracted cases, 
where there is much constitutional affection, it is inadmissible. 
It has been used in scrofula, combined with hemlock and anti- 
mony. The subjoined prescription is from Frankel.* Mercury 
should never be given to salivation in this disease* 

Among the remedies of a tonic nature which have been con- 
sidered almost as specific, is the chloride of barium, (muriate of 
baryta.) used by Hufeland in Germany, and Crawford in St. 
Thomas' Hospital, in London. It has been highly extolled by 
many German, English and French physicians. Hufeland 
recommends it in such cases as are attended with increased 
irritability and inflammation. It ought to be given with great 



* # Hydr. Subm. 

Antimon. Oxysulph, aa. gr.j\ 
Extr. Conii, gr. j. 
Sacch. Alb., 3j. M. 
ft, Pulv. dent. tal. dos. No. xij. 
To children under two years, half a powder morning and evening. To older 
children a whole one. 



EXCERNENT SYSTEM. 301 

caution, as violent griping may be caused by an overdose, 
together with hypercatharsis and inflammation of the throat and 
stomach. Pine! and Hebrerard have seen these effects even 
from a single grain of the medicine given every other day. I 
have never used it; but if such are the violent effects occa- 
sionally arising from its use, prudence would dictate its aban- 
donment altogether, notwithstanding the high encomiums be- 
stowed on it by the distinguished physicians above mentioned, 
particularly as we are in possession of a much safer remedy, 
which has within a few years been introduced into practice, 
and which has almost taken the place of other measures of 
treating the chronic engorgement or indurated glands in scrofu- 
lous affections. 

Iodine was first introduced into practice by M. Coindet, of 
Geneva.* Its operation is decidedly tonic, as the augmenta- 
tion of appetite, and the increased strength of those who use it 
judiciously, and in small doses, proves. Lugolf asserts that he 
never observed emaciation to occur from its use, when pro- 
perly employed, but on the contrary, an increase of vigour was 
the result. Its action on the nervous system increases that of 
the heart and arteries, and restores the functions of the san- 
guiferous and organic systems, as remarked by Brera. These 
observations have been confirmed by SirG. Clark, J3audelocque f 
and others. 

The symptoms usually observed from its internal use, are an 
increased flow of urine and improved appetite, the alvine eva- 
cuations are rendered more frequent, and at times the action of 
the salivary glands is increased. Although these are the ordinary 
symptoms produced by the use of iodine, yet, in some instances, 
these salutary results have not followed ; it will therefore be 
necessary carefully to watch the effects of the medicine, and 
to suspend its use if an opposite effect is produced, to be re- 
newed at the interval of a week. Sometimes it is excessive in 
its action on the bowels, and accompanied with severe colic ; 
it must, under these circumstances, be suspended for a time, as 
it is evident that a morbid excitability of the mucous membrane 
exists, forbidding the employment of this remedy. 

From its stimulating effects, its administration ought to be 
limited to those cases in which there is no inflammation in the 
tumours, and where indurated tumours remain after the dis- 
ease has passed through its stages. M. Lugol recommends the 
use of mercury to precede the employment of iodine, as the 
unloading the intestines, and the establishment of the intestinal 



* Bibliotheque Universelle, July, 1820. 

t Mem. sur l'Emploi de l'lode, etc., Paris, 1829. 



302 



DISEASES OF CHILDREN, 



secretions, greatly favour the operation of the latter on the sys- 
tem. All practical writers refer to the necessity of commencing 
the treatment of scrofula by cathartics, as recommended 
above. 

In very irritable conditions of the system its use should be 
avoided, until some energy is restored to the organs by hy- 
geinic measures. A removal to the country, or to the sea-side, 
hot weather, together with the use of mild bitter infusions, will 
very naturally precede the employment of iodine, under the 
circumstances just mentioned. 

It is usual to prescribe iodine in conjunction with the hydrio- 
date of potash, the solubility of the former being augmented by 
this combination. The subjoined prescription is that employed 
by M. Lugol, and is preferred by him to the tincture of iodine, as 
a precipitate usually forms after it has remained for a short 
time, and water always causing a precipitate in the simple alco- 
holic tincture.* The formula of Lemasson is also given be- 
low.f 

Some will bear with advantage much stronger doses of 
iodine than that of M. Lugol, but it ought to be commenced in 
the minimum dose, and gradually increased. M. Baudelocque, 
commencing with the proportions similar to those above men- 
tioned, increased it by degrees to six grains of the hydriodate 
of potash, and three grains of iodine daily. 

In the use of this medicine the greatest precaution should be 
observed, and the dose should never be increased without care- 
fully watching its effects ; and upon the slightest appearance 
of nervous irritability, or derangement of the functions of the 
stomach, its use must be suspended. Among the unpleasant con- 
sequences occasionally resulting from the employment of iodine, 
are distressing pains in the chest and bowels, and in some, very 
severe convulsions. The permanent effects are palpitations, 
cough, debility, emaciation, wakefulness, trembling, headache, 
and tumefaction of the legs. When any untoward symptoms 
arise from iodine, mucilages of starch and anodynes, with 
emollient and anodyne enemata, will counteract them. The 
experience of physicians, generally, as to the proper time for 
giving iodine, is shortly after a meal ; it is less apt to produce 



* fy Iodini, gr. v. 

Potass. Hydriod., 3ss. 
Aq. Destill., §ij. 
Two drops twice a day to children 
under seven years, gradually increased 
to five drops. Sixteen drops will be 
the maximum dose for children above 
seven. To be given in sweetened water. 



t # lodini, 3j. 

Potass. Hydriod., 3ij. 
Aqua? Destill., gj. 
Contere Iod. et Potass, 
hydriod. in mortario, 
vitreo, sensim. 
Aquae Destill., et adde. 
Four drops thrice a day, i 
sweetened water. 



little 



EXCERNENT SYSTEM. 303 

nausea at that time than when taken fasting. About an hour 
or two, therefore, after eating, appears to be the best time for 
giving it, and some have even recommended animal food as 
an adjuvant. 

M. Lugol has strongly recommended ioduretted baths ; but, 
from the rapid evaporation of the iodine, it is doubtful whether 
much benefit can arise from their use. The proportions used 
by him for children between the ages of four and seven years, 
is from thirty to thirty-six grains of iodine, and sixty to seventy 
grains of hydriodate of potash, to nine gallons and a half of 
water. 

There have been a vast number of other articles used at dif- 
ferent times in the general treatment of scrofula, from their 
real or supposed effects on the lymphatics, such as calamus, 
balsam of sulphur, iron, mezeron, sarsaparilla, etc. ; and various 
narcotics have also been employed, and lauded as specifics, 
as hyoscyamus digitalis, solanum, asclepias, and some others ; 
they however possess no other effects than as assistants to 
other and more rational means, for the purpose of allaying 
a morbid irritability. 

With respect to the local measures to be used, these must, 
like others, be directed altogether by the condition of the part ; 
if the tumours appear red, and possess much tenderness on 
touching them, leeches should be applied, and the inflammation 
subdued by the usual means. On no account must stimulant 
applications be made, in such a condition of the parts. 

In general, however, there appears to be at the commence- 
ment a simple congestion of the gland by the lymph, and de- 
mands a local treatment corresponding with general measures. 
The peculiarly stimulating effects of iodine will, therefore, ren- 
der it necessary to adopt it in connection with the internal use 
of the same article. 

When externally applied, it causes a yellowish stain on the 
skin. There is but little hazard in the use of it when externally 
employed, for as the part heals it becomes less sensible to its 
influence ; and the evident disappearance of the tumour is a 
sufficient indication of the proper effects of iodine, in time to 
prevent any possible injury arising from its excessive employ- 
ment.* Dr. Hildreth, in the American Journal of the Medical 
Sciences, for August, 1840, extols highly the iodo-hydrargyrate 
of potassium in glandular enlargements.! 



* ~fy Iodinii, gr. xij. 
Potassee Hydriod. 
Adipis, §j. M. 
fy Iodid. Plumb., 3j. 
Adipis, §j. M. 



t ~fy Deutiodid. Hydrarg., gr. viij. 

Hydr. Potass., 3ij. 

Axcung., §j. M. 
To be applied to the tumours, two or 
three times a day. 



304 DISEASES OP CHILDREN. 

Where the tumours break, they should for a short time be 
covered with a soft poultice ; and when the discharge is some- 
what abated, the application of stimulant lotions is in general 
indicated, as solutions of alum, # sulphate of zinc,f or nitrate of 
silver. J In very indolent conditions of the ulcers, great benefit 
is derived from a saturated solution of sulphate of zinc. A 
highly irritable state of the parts sometimes exists, which re- 
quires soothing applications and a poultice of hemlock, or a 
lotion made with the extract of conium will be peculiarly 
beneficial to allay this morbid irritability. If fungous excres- 
cences arise, they should be removed with burnt alum or 
nitrate of silver ; the latter, also, when applied to the edges of 
the indolent ulcer, greatly favours the establishment of a new 
action in the part, and is the best application of an escharodc 
nature that can be used, as it leaves but little irritation and 
inflammation. When any escharotics produce an increase of 
local excitement, it should be allayed by the application of 
poultices, and cataplasms of some mild narcotic. 

The indolent and permanently enlarged glands have been 
successfully treated by compression, care being taken not to 
apply it until the inflammation is removed. Scrofulous ulcera- 
tions, also, have been treated upon a similar plan, and the 
method of Mr. Baynton in treating ulcers on the legs, success- 
fully used. After the ulcers are covered with simple dressings, 
a soft compress should be applied, and the whole bound closely 
by means of adhesive straps, where the situation of the ulcers 
will admit of it ; about the neck pressure should be avoided 
over the pomum Adami, lest respiration should be affected. 

TABES MESENTERICA. 

This disease, known also by the names mesenteric scrofula, 
atrophia mesenterica, chronic mesenteritis, is more frequent in 
children about the period of weaning than in after life ; if we 
except the time intervening between this period and the age 
of seven years. It has by some been confounded with remit- 
tent fever, which occurs in children, but the latter may exist 
without any affection of these glands ; and the only resemblance 
between them is, that a deranged state of the chylopoetic 
organs exists, and that fever will in some stages of the disease 
attend it, and thus render it liable to be confounded with re- 
mittent fever. 



ft Alumen, gr. v. t ft Zinci. Sulphat., gr. iij. 

Solve in Aquae, ^iss. M. 

Aquae Ros., gj. M. 

* ft Argenti Nitratis, gr. iij. 
Aquae Destill., 3j. 



EXCERNENT SYSTEM. 305 

The affection known as the disease of the mesenteric glands, 
and which consists in an enlargement of these bodies, accom- 
panied with great emaciation and hectic fever, a peculiar form 
of chronic disease attendant on a strumous diathesis, is what 
is proposed to be considered under the present title. Some 
degree of inflammation attends it, chiefly during the progress 
or towards the termination of the affections ; and although the 
acute inflammation and true suppuration of the part must be 
regarded as a distinct affection, yet in many instances the 
disease known as the tabes mesenterica may be greatly modi- 
fied, and approach more closely to the ordinary action of in- 
flammation, according as a less degree of the strumous diathesis 
is in the system, the complications in both being an inflammation 
of the mucous lining of the intestinal tube. The diagnosis is, 
under such circumstances, a secondary consideration, for the 
treatment will be similar in both, as the disease then assumes 
one of the forms of enteritis. When, from an accurate investi- 
gation of the case, we are satisfied that its slow progress, and 
the absence of fever at the commencement, give evidence of 
the non-inflammatory nature of the disease, it may then be 
referred to the developement of a strumous affection, analogous 
to that already described. In this form of the disease the 
wasting away of the frame is an invariable occurrence, and 
hence the name tabes, which, although describing but a mere 
symptom, is yet an important and very striking designation of 
the disease. 

Etiology. — Children of a strumous habit of body are those 
who are predisposed to enlargements and softening of the me- 
senteric glands, and indeed they are the glands where the scro- 
fulous disease shows itself the soonest. Sir Astley Cooper re- 
marks that they are, next to the cervical glands, the most liable to 
be affected with this disease ; but according to the results of the 
investigations of the distinguished anatomist, Meckel, and of 
Andral, the latter undergo the changes which impart the pecu- 
liarities of scrofula sooner than any other part of the system. 

It is unnecessary here to repeat the usual marks by which this 
predisposition may be suspected, as they have already been 
mentioned in the preceding section. That this condition of 
system exists in tabes mesenterica, has been the opinion of 
several writers, whose opportunities of examination have enabled 
them to discover, after death, the simultaneous existence of this 
disease and phthisis. Portal* and Guersentf have both found 
tubercles in the lungs of those that died with tabes mesenterica. 

* Sur La Phthisie de Naiss., Mem. de l'Acad. des Sciences, 1781. 
t Diet, de Med., art. Carreau. 

39 



306 DISEASES OP CHILDREN. 

It has been supposed that a prominent abdomen is an evi- 
dence of the predisposition to mesenteric affection; this, how- 
ever, is not always to be regarded as a sign of the existence of 
the disease, even when it is developed, much less can it be re- 
garded as a certain evidence of a predisposition to it. A full 
and prominent abdomen, when connected with other signs of a 
lymphatic temperament, point out the strumous diathesis, and 
may rationally lead to the suspicion of an enlargement of the 
mesenteric glands, when symptoms appear which are pathogno- 
monic of the disease. As a sign of the predisposition to the dis- 
ease, as remarked by Evanson and Maunsell, it has been greatly 
overrated, if, indeed, it possesses any: the mesenteric glands 
adding nothing to the size of the abdomen until the disease has 
advanced to some extent. This remark I have had some oppor- 
tunities of verifying ; and at the present time have a little 
patient who exhibits unequivocal symptoms of the existence of 
disease of the mesenteric glands from a scrofulous predisposi- 
tion, without any inordinate size of the abdomen. Guersent* 
also positively asserts, that extensive mesenteric disease has 
been found in instances which came under his notice, where, 
during life, no greater enlargement of the abdomen existed 
than is usual in children of the same age in health ; and main- 
tains that a large abdomen is no sign of the liability of the 
subject to this affection. 

Besides the strumous predisposition, the active developement 
of these glands, which is a gradual process from birth to the 
period of teething, renders them liable to take on diseased action. 
Accordingly, at the time when the entire digestive system un- 
dergoes a change, and all the glandular apparatus immediately 
connected with the process of digestion is excited to an increase 
of its natural functions from the requisitions of the system 
for a different species of food, these glands, with others, exer- 
cise a great increase of their natural actions. The most ac- 
curate observers have noticed that the disease, for the most 
part, makes its appearance about the eighth month, to a year.f 
The developement, therefore, of the mesenteric glands, like 
that of other parts of the system, gives a very strong predispo- 
sition to disease, easily excited on the application of the usual 
causes. 

The exciting causes are those which have already been enu- 
merated, as producing a congestion and enlargement of the 
lymphatic glands ; such as insalubrious air, deficient exercise, 
but more particularly improper food, and the change occurring 

* Diet, de M6d., art. Carreau. 

t Andral, Path. Anat., vol. ii. p. 448. 



EXCERNENT SYSTEM. 307 

in the diet at the time of weaning. This latter is a very com- 
mon cause, where, from the inability of the mother to nurse 
her offspring, it is necessarily weaned before the proper pe- 
riod, while artificial food is substituted for the breast milk. 

As was remarked when treating of scrofula, diet itself is not 
so invariably a cause of mesenteric disease as it would gene- 
rally be supposed ; but when to impoverished diet are added the 
baneful effects of bad air and crowded habitations, this disease 
is most apt to make its appearance. The most common cause 
in dietetics is not so much, perhaps, a poor or vegetable diet, 
as food that is altogether inappropriate, such as the too early or 
too frequent use of animal food, broths, &c. 

The inflammation of the intestinal mucous membrane is con- 
sidered as the principal, if not the sole cause of enlarged and 
diseased mesenteric glands, by many pathologists of the 
present day. Dr. Cheyne, in his valuable work on the abdo- 
minal diseases of children, observed that this was a frequent 
cause of the diseased glands in the cases which came under 
his notice — an important fact to recollect in the treatment 
of the affection, the nature of the exciting cause having a 
direct bearing on the treatment. The disease, when produced 
in this manner, is usually marked by symptoms which indicate 
the presence of an inflammation more or less severe from the 
commencement, and will, therefore, come under the notice of 
the physician, as a disease at first differing from that now un- 
der consideration, and leading to it as a result or consequence. 

Besides, therefore, the non-inflammatory developement of 
tabes, any of the causes which will produce enteritis, or cause 
an irritation in the mucous membrane of the intestines, may 
become a source of enteritis. The retrocession of cutaneous 
eruptions may consequently produce this disease, as this fre- 
quently excites inflammation of the mucous lining of the 
bowels. 

Semeiology. — It is extremely difficult, by any precise symp- 
toms, to detect at first the existence of enlarged mesenteric 
glands ; all the varying symptoms of gastric and intestinal in- 
digestion and inflammation being more or less evident, and are 
the necessary attendants on the disease of these glands, when 
they exhibit any symptoms of disorder ; for there have occurred 
cases where they have been found in a state of suppuration, 
without any suspicion of such disease existing. 

The commencement of the disease is exceedingly obscure ; 
and the only cause of suspicion is found in the existence of 
a strumous diathesis, and the appearance of scrofulous enlarge- 
ments about the neck, while the obstinacy of the symptoms of 
disordered digestion, and their repeated occurrence, will almost 



80S DISEASES OF CHILDREN. 

confirm the suspicion, that the mesenteric glands are likewise 
the seat of the chronic engorgements, to which they, in common 
with the lymphatic glands, are liable. 

The affection has been divided into three distinct stages ; the 
first, as has just been observed, being very difficult to distin- 
guish. This division is generally adopted by practical writers, 
although, like all other arbitrary divisions of disease, is at times 
very difficult accurately to distinguish. The following are the 
symptoms which have been assigned to each of these stages 
by Capuron, Gardien, and other writers, and which in the 
two last stages may easily be recognised.* 

At first the child loses its ordinary vivacity ; becomes sad, 
pale and feeble. The digestion is deranged ; the appetite nearly 
lost ; the abdomen appears flatulent, swelled and tense, more 
especially towards night. The alvine evacuations are occa- 
sionally liquid, with intervals of costiveness. The lungs exhale 
an acid odour ; respiration is irregular, and the pulse intermit- 
tent. The urine appears white and milky. Cramps sometimes 
occur in the limbs, which become very feeble. The face is 
thin and wrinkled, and the skin is dry and harsh. All these 
symptoms, it is very evident, are. common to the ordinary 
gastric and intestinal derangements. 

The second stage, in which the peculiarities of the disease are 
more evident, may be known by the variable appetite ; usually, 
however, it is exceedingly voracious, without any improvement 
in the appearance of the child, who continues to become 
greatly emaciated. The food taken appears to cause distress, 
producing borborygmus, and other symptoms, caused by an in- 
ordinate mass of undigested matter in the bowels. The abdo^ 
men is largely distended, and it is at this stage of the disease 
that the indurated glands may be felt, solid, knotty, and isolated i 
the only symptom on which M. Guersent relies, as an une* 
quivocal evidence of the existence of tabes mesenterica. 

When an examination of the abdomen is made for the pur- 
pose of ascertaining the existence of these diseased glands, it 
should be done while the bowels are empty, when the glands 
may be felt, and giving pain on pressure. The pain is only felt 
when the glands themselves are pressed. This is a diagnostic 
sign of some importance, for there is evidently but little or no 
inflammation of the intestines when no pain is produced orl 
pressing the abdomen in the usual manner. 

It has been observed that the pain of simple strumous mesen- 
teric glands is not increased by pressure on the abdomen ; they 

* Traits des Mai. des Enf., par J, Capuron, p. 416. Diet des Scien. M€d., art. 
Mai. dea Enf. 



EXCERNENT SYSTEM. 309 

cannot, therefore, be always complicated with a phlogosed state 
of the intestines. When the child is old enough to give an 
account of the pain attending the disease, it is described as 
sharp and deep seated, not continued, but recurring at intervals 
like the griping pain of colic, but situated more towards the loins. 

In this stage the urine flows in small quantities. The stools 
are very irregular, and occasionally entirely suspended ; some- 
times they are soft, and present a very natural appearance ; 
at other times, and much more frequently, they are of a white 
or chalky appearance, which has been regarded as peculiar to 
this disease. Worms are often found in the alvine discharges. 

The body becomes exceedingly emaciated, the face pale, and 
the features sharp, while the abdomen gradually enlarges. In 
this stage a fever of a very irregular type makes its appear- 
ance. It is at first obscure and intermittent, but if the disease 
is attended with inflammation of the mucous coat of the intes- 
tines, it becomes more distinct and acute, but for the most part 
assumes the remittent form. When it is simply the effect of 
irritation caused by the preternaturally enlarged glands, its 
exacerbation occurs towards evening, accompanied with great 
restlessness and a rapid pulse, beating from 120 to 130 in a 
minute. This fever is preceded by severe chills, and ends in 
profuse sweating, with colliquative diarrhoea ; it is a true hectic 
fever, the paroxysms terminate towards morning, to be re- 
newed at the close of the day. There is but little disturbance 
of the intellectual faculties ; and listlessness and indifference to 
surrounding objects, and avoidance of all exertion, are the prin- 
cipal manifestations of any change in the sensorial powers. 

In this stage, also, it is not unusual for anasarca to take place, 
if the tumours are large, from their pressure on the veins. 
From the same cause, also, a change occurs in the functions of 
contiguous parts, and the actions of the stomach, liver and 
kidneys, are very materially impaired. 

During the entire progress of the disease, but more espe- 
cially at the period designated as its second stage, a variation 
of the symptoms will be observed in different cases, according 
to the complication of the mesenteric affection, with phlogosis 
of the intestines. When the disease of these glands exists in- 
dependently of any such complication, or when the latter is 
very light, the accompanying fever bears little or no resem- 
blance to the remittent fever of infants, which is its character 
when the inflammation of the mucous membrane of the intes- 
tines is severe. A close attention to the symptoms, principally 
by examining the condition of the abdomen on pressure, will 
sufficiently enable the physician to detect the evidences of in- 
flammation of the bowels. When this exists, the disease is 



310 DISEASES OF CHILDREN. 



r 



usually rapid in its progress, and differs in no respect, in its 
manifestations and results, from enteritis. 

In the last stage, this inflammation almost invariably exists, 
even if it should have been absent at the other periods of the 
disease. The glands have passed from their indurated condi- 
tion, and become softened or suppurated. The fever is deci- 
dedly hectic, and great prostration of strength ensues, with 
extreme emaciation. Excessive discharges by stool take 
place, and pus, mixed with streaks of blood, appear in the 
alvine evacuations. The abdomen becomes more tumid and 
tender to the touch, serous effusions in the cellular tissue and 
peritoneal cavity increase, and the child dies in a state of com- 
plete marasmus. 

It is a subject of acknowledged difficulty, accurately to distin- 
guish this disease from others which affect the abdominal organs 
of children. One of the most unequivocal signs of the presence of 
enlarged mesenteric glands, is the existence at the same time of 
scrofulous tumours in other parts of the body, while the symptoms 
above mentioned show the disordered state of the primse vise. 
Where these signs also are absent, the tubercular affection of the 
mesenteric glands may be suspected, when the child exhibits the 
usual appearance of a scrofulous habit ; while fever, which usually 
attends gastro-intestinal inflammation, is absent. The nature of 
the alvine discharges, in connection with other symptoms, will 
throw some light on the nature of the disease. If there exist 
a diarrhoea, the food taken appears for the most part to excite 
it ; and the crude nature of the evacuations will show that it 
has been rapidly urged through the bowels, from an exalted 
action, produced by the increased susceptibility to impressions, 
which follow an inflammatory excitement. The stools, also, have 
a mucous or slimy appearance, showing an alteration in the 
secretions of the mucous surface. The pain will, for the most 
part, be increased immediately on taking food, when there is 
any gastro-intestinal inflammation ; and where there is inflam- 
mation, especially of the small intestines, pain will immediately 
be increased on pressure. The discharges, on the contrary, in 
the scrofulous affection, commencing in its ordinary manner, 
although there may appear in them ill-digested food, are yet 
destitute of the morbid secretions which attend inflammation of 
the mucous membrane. 

All the symptoms of an abdominal nature are equivocal ; 
but when they present a deranged condition, and the child has 
the usual symptoms of a scrofulous diathesis, and with them 
continues to grow emaciated, while- the appetite is good, or 
perhaps voracious, the strong presumption is, that the mesenteric 
disease is the cause of all the untoward symptoms. 



EXCERNENT SYSTEM. 311 

Morbid Anatomy and Pathology. — On a post-mortem exa- 
mination, the exterior of- the body presents a rough and ashy 
appearance, the skin is dry, and from the great emaciation of 
the body, seems almost in some parts closely adherent to the 
bones. On opening the body the mesentery is found often in- 
filtrated with pus, and studded with engorged and tuberculated 
tumours, in various states of disorganization ; some partially 
suppurated, and others totally destroyed. Those which are in 
the earliest stage are red, and somewhat increased in size. 
These glands and tumours are of various sizes, from that of a 
pea, to that of a hen's egg. They are often agglomerated into 
masses of great size ; and those which are advanced to the 
second stage of disorganization, are of a dull, white colour, and 
firm consistence. The glandular structure of the mesenteric 
glands is at times found entirely altered, and tubercular matter 
deposited in its place. This tubercular deposit also appears 
on the surface of the glands, which gives them the appearance 
of being much enlarged ; but, according to Andral, it is not 
so, but it is the effect of the additional deposit of tubercular 
matter, commencing either in the centre, or in several points of 
their bodies. It has been supposed to occur in the cellular 
tissue ; for injections show that the permeability of the lym- 
phatic vessels, through the glands, remains the same as if there 
were no disease, for injections readily pass through them. 

These tumours, when softened, exhibit precisely the same 
characters as tubercular matter in other parts, the caseous 
appearance being in every respect like that observed in tuber- 
cular matter of the lungs in phthisis. Besides these lesions in 
the part which is the immediate seat of the disease, various 
others are occasionally found. The peritoneum is sometimes 
inflamed, with adhesions and effusions in its cavity. Ap- 
pearances of inflammation also have been found in various 
parts of the intestines, with ulcerations of the mucous surface. 
These, it has been remarked by some observers, are not uni- 
formly the case in enlargements of the mesenteric glands, and 
their existence is as frequent without a diseased condition of 
the glands, and they have no dependence on each other, as 
cause and effect, notwithstanding that this theory has had such 
strong advocates.* The analogy offered by the enlargement 
of the cervical lymphatic ganglia by a primary affection, with- 
out being traceable to an abnormal condition of the adjacent 
parts, with which it is connected, shows conclusively that an 
independent disease can exist in them. 

It is very rare that there are not found tubercles in other 

* Dr. Joy, Cyclop. Prac. Med., art. Tabes Mesenterica. 



312 DISEASES OP CHILDREN. 

parts ; the liver generally contains some, and they are also 
found on the peritoneum. The greatest number exists in the 
lungs, as we learn from the dissections made by Guersent, in 
the Children's Hospital at Paris.* 

The disease is then of a scrofulous nature, depending for the 
peculiarities of its manifestations on the developement of the 
strumous changes in the mesenteric glands and the adjacent 
parts, and analogous in every respect to similar alterations in 
other glands and tissues. Like all other diseases, it scarcely 
ever exists without its complications. It is from this cause that 
much diversity of opinion has prevailed as to its precise nature ; 
for diseases affecting the primse viae of children are much more 
liable to the admixture of other derangements, as one part 
can hardly ever be affected without other portions being like- 
wise disturbed in their functions, or suffering perhaps from 
organic changes. Inflammation not only occurs in the mucous 
membrane of the bowels, but traces of it are found in the peri- 
toneum, and tubercles are discovered both in this serous mem- 
brane and in the liver. The complications are important in a 
practical point of view ; and the early appearance of inflammation 
demands a course of treatment which the judicious physician 
would hesitate to adopt, under circumstances which exhibit at 
once a tendency to the fatal debility and marasmus which 
characterize the disease in question. 

It has been common, since the doctrines of Broussais have 
been introduced, to regard the disease, in every instance, as 
produced by an inflammation of the mucous membrane of 
the intestines. Tubercular matter is now regarded as a dis- 
tinct morbid product, and the mesenteric glands may become 
tuberculated like other glands ; and this change is accompanied 
with inflammation at some period of the disease, but is not ne- 
cessarily preceded by it. That these glands become inflamed 
and suppurate, from the cause just mentioned, no one can deny ; 
for there is no reason why we should question the analogy 
between them and other glands, as those of the groin, which 
it is well known become inflamed, and suppurate from trans- 
mitted continuous inflammation. But such is evidently not 
the disease in question, for it is one purely of a tuber- 
cular nature : it has been regarded as such by Bichat,f Sir A. 
Cooper,J Andral,|| Carswell,§ and others. It may be generated 
in the part itself, without being transmitted from another. 

* Loc. Cit. 

t Anat. Patholog. d'apres un manuscrit autographe, etc., P. A. Beclard. 

t Lancet, vol. iv. p. 102. 

41 Morbid Anat., p. 209. 

§ Path. Anat., fosic. iv. ; Lond. 1834. 



EXCERNENT SYSTEM. 313 

Whatever be the theory of the actual developement, it would 
appear, from its nature, to be capable of being excited into 
action, in a manner different from that of ordinary inflammation 
and suppuration, and not necessarily dependent first on an in- 
flammation of the mucous membrane. Such inflammation as 
we see in other glands, results, for the most part, in real genu- 
ine suppuration. There exists in these, as in other glands, a 
real inflammatory enlargement, which follows inflammation of 
the bowels, and which may be an attendant of the remittent 
febrile affection of children. This distinct disease has been de- 
scribed by Pemberton ; and although an enlarged condition of 
the glands was found, yet it was destitute of the peculiar 
cheesy matter existing in tuberculated glands. It is, he says, 
an enlargement from the irritated and inflamed membrane with 
which they are surrounded.* 

As was before remarked, the disease is rarely found uncom- 
plicated with irritation, inflammation, and at times even ulce- 
ration of the mucous lining of the intestines. This inflammation 
in those of a scrofulous habit is liable to run into tabes, and the 
disease thus produced is very easily confounded with the sim- 
ple ordinary inflammation, excited in the same manner. In- 
flammation, both in the glands and in other parts, is also influ- 
enced by the amount of the strumous diathesis developed in 
the system, and like other forms of scrofula, will be modified in 
its appearance and progress by this condition of the system. 

Treatment. — The treatment must be, as to the general 
principles, similar to that pointed out for the management of 
scrofula. It will, therefore, be necessary to adopt similar hy- 
geinic rules, and to give the patient, if possible, the benefit of good 
free air in a healthy district of country, and by good nourishing 
food and plenty of exercise, suited to the age and vigour of the 
child, give the constitution an opportunity of attaining a state 
of healthy developement. It is unnecessary here to repeat 
what has been already said on this subject. The remarks under 
the head of scrofula are applicable to the present disease ; bear- 
ing in mind that the seat of the affection, and the great liability 
to complication by inflammation of the mucous surface of the 
bowels, render great circumspection necessary in the use of 
stimulating or nutritious food. 

It will be of the greatest importance in the treatment of this 
disease, throughout all its stages, to recollect the frequent liabi- 
lity to an inflammatory action in the mucous membrane ; and 
to examine closely at the first appearance of disease, attended 

* A Practical Treatise on the Various Diseases of the Abdom. Viscera, by C. R. 
Pemberton, M. D. ; Lond. p. 17. 

40 



314 DISEASES OF CHILDREN. 

with derangement in the actions of the chylopoetic viscera, 
whether there do not exist some degree of inflammation in 
these parts, or their dependent membranes, and other organs 
with which they are connected. When these are found to 
exist, the treatment should be commenced with the abstraction 
of blood, by means of leeches applied to the surface of the 
abdomen, and the use of warm fomentations, warm bath, and 
frictions over the surface of the body. Such measures will 
form a powerful counter-irritation to the disease, even if there 
should not be inflammation decidedly manifested by tenderness 
on pressure, but only symptoms of evident derangement of 
the abdominal organs, which would lead us to suspect the pre- 
sence of diseased glands, and if much febrile action attends the 
other symptoms. This course will be more beneficial at the 
commencement of the disease, before debility or emaciation 
has ensued. Indeed, it is scarcely applicable at any other 
period, for the child can rarely ever bear the repetition of the 
abstraction of blood, without serious debility being the result, 
when the glands are the seat of the scrofulous affection. The 
local inflammation and irritation most commonly exist, to a 
greater or less degree, in all these affections at first ; and it is 
not incompatible to resort to these measures for its removal, 
while efforts are at the same time made to invigorate the gene- 
ral system, principally by the measures already mentioned. 
To tell the precise point when measures of a local depletory 
nature ought to be suspended, is sometimes a question of great 
difficulty, especially in the disease before us. That it cannot be 
pursued, and the treatment mainly conducted on the supposi- 
tion that it is essentially inflammatory, all experience fully 
justifies. 

It is also a safe practice, and one which is borne out by expe- 
rience, to use mild aperients where the bowels are sluggish in 
their action ; that of calomel and rhubarb will be decidedly the 
best : the former, from its well known action on the secretions 
generally, and the latter, from its property of controlling exces- 
sive discharges. Purgatives were formerly very much in use 
in the treatment of this disease ; of late they have been almost 
entirely discarded, and nothing allowed to pass to the internal 
surface of the bowels but the blandest substances. Although, 
when injudiciously used, they unquestionably greatly aggravate 
irritation in the mucous surface of the bowels, yet daily obser- 
vation proves, also, that by their effects on the secretions they 
also relieve inflammation in the very parts where they exert 
their irritating properties. Besides, in this disease, and in all 
affecting the chylopoetic viscera, we are not certain that the 
mucous membrane always continues inflamed throughout its 
whole process, even if it were so at the commencement. 



EXCERNENT SYSTEM. 315 

An altered condition of the secretions of the liver and intes- 
tines, known by a foul tongue, and dark-coloured discharges, 
highly offensive in their character, will, for the most part, indi- 
cate the necessity of aperient medicines. The relief afforded to 
the vessels by the free secretions, produced by medicines of this 
nature, will not only tend to relieve the local affection, but will 
likewise impart an increased vigour to the constitution. The 
indiscriminate and persevering use of cathartics has brought 
remedies of this nature too much in disuse, especially where the 
viscera of the abdomen are implicated in the disease ; but 
under the circumstances just named, those of a mild character, 
and which exert their principal effects on the liver, will be such 
as will be needed. When these are indicated, calomel should 
have the decided preference, and, as before remarked, will be 
best combined with rhubarb ; or a small dose of calomel at 
night, followed by a combination of rhubarb and sulphate of 
potash on the following morning. This course should be 
adopted for a week or two, intermitting every third day, until 
a decided improvement is seen in the alvine discharges. It has 
been the custom in Europe to administer at the same time some 
mild, bitter infusion, combined with a narcotic, for the purpose of 
procuring a tonic effect, and allaying constitutional irritation. 
These means may advantageously be adopted where there is 
no fever present, or any mark of inflammation. Such cases 
will sometimes occur, and be decidedly benefited by this 
course. 

A combination of these means is recommended by Under- 
wood, who, after using small doses of calomel two or three 
times a week, advises the sub-carbonate of soda on the suc- 
ceeding day, or an infusion of senna and burnt sponge, with 
which he was almost certain of effecting a cure — regarding 
the purgative system as the most essential to the cure of this 
dangerous disease, and even to be used when there is a loose 
state of the bowels. After the bowels had been thus freely 
acted on, he then combined small doses of calomel with ipecacu- 
anha, cicuta and Colombo. 

All practitioners agree as to the benelicial effects of mercury 
in some form, given only to influence the secretions, but not 
to produce salivations. Lloyd, for this purpose, recommends 
blue pill, or Plummer's pill, followed by a decoction of sarsapa- 
rilla. Abernethy uses mercury, combined with rhubarb and 
ginger, for the purpose of restoring the secretions and imparting 
tone to the stomach, and thus improving the digestive organs. 
All these various combinations may be found useful, and the 
union of a tonic with an aperient, even immediately after local 
depletion, may in reality be found useful practice ; for a local 



31G DISEASES OF CHILDREN. 

affection, like that now under consideration, will not be found 
to be aggravated by the increased vigour imparted to the 
constitution by a mild tonic and improved digestion. The 
form of mercury, which is generally the most useful in the 
deranged secretions in children, and especially if accompanied 
with any degree of looseness, is the hydrargyrum cum creta, 
combined with rhubarb. Formulae, which are applicable to the 
present disease, have already been given. Whatever be the 
form in which this medicine is given, it should never be carried 
so far as to affect the constitution. Frictions, therefore, of mer- 
curial ointment, which for a time were much in use, are inad- 
missible in this disease, for they produce no action on the 
system until absorbed, when the constitutional effects will 
produce very serious consequences in a strumous habit. It 
can only be given with safety in such quantities as will procure 
an increased secretion from the liver and intestinal surface. 

Where there exist good reasons for not using calomel, 
rhubarb, combined with sub-carbonate of potash, or sulphate 
of potash, will be found useful, from its mildness, and may be 
employed daily, for some weeks, where purging is deemed 
necessary. A most important means should not be overlooked 
in the management of this disease, that is, the employment of 
frictions and externa] stimulants throughout the whole course 
of the disease. This method of treating chronic affections is too 
much neglected ; but it is among the most useful which can be 
adopted, for it not only produces a counter-irritation, but, by 
the active influence on the capillary system of the surface, 
powerfully excites it into action, and thus produces a constitu- 
tional effect on the capillary system generally, from the exten- 
sive sympathy which exists with the vessels and nerves of the 
dermoid surface. The body and limbs may be frequently 
rubbed with some stimulating liniment, while the ointment of 
iodine, which exerts so powerful an influence over the glandular 
system, may be rubbed over the abdomen twice a day. The 
ointment of the hydriodate of lead is considered as preferable, 
on account of its not causing so great an irritation on the sur- 
face to which it is applied as other forms of iodine. Formulas 
for applications of this nature have already been given under 
the head of scrofula. 

It was before observed that tonics are at times called for in 
the treatment of this disease. They were much more freely 
used in former times than at the present day ; but while they 
were formerly too indiscriminately resorted to in the early 
stages of the disease, and greatly relied on for its cure, they 
have been too much disregarded in the present day. When- 
ever tonics, whose action is direct on the digestive functions, 



EXCERNENT SYSTEM. 317 

are used, they ought always to be combined with some aperient 
medicine, whereby the secretions are excited, while a vigour is 
imparted to the digestive organs. When such are deemed 
necessary, which can only be the case when there is an entire 
absence of all febrile action, the sub-carbonate of iron, com- 
bined with rhubarb and Colombo, is one of the principal means 
employed by Sir Astley Cooper in the treatment of scrofulous 
diseases generally. With respect to the employment of iron, 
it is only useful in cases of extreme debility and a leucopathic 
state of the system, where the serous fluids predominate. In 
such cases, after the employment of a proper alterative course, 
and when there is evidently a great want of tone, iron may be 
useful in overcoming the glandular obstructions, by the energy 
and vigour it imparts to the circulation. Notwithstanding its 
recommendation from high authority, it should be given to chil- 
dren with great circumspection, as it is a powerful excitant, and 
only under the circumstances just mentioned can it be consi- 
dered as useful. Chalybeate mineral waters have also been 
found greatly to benefit those suffering from this, as well as 
other forms of scrofulous diseases, but they are not to be used 
when there is any inflammation of the glands, or of the intes- 
tinal or gastric mucous membrane. They should never be re- 
sorted to when there is any indication of such irritation with 
febrile action. 

As a tonic and deobstruent the muriate of barytes has for a 
long time been held in high repute in Europe. Its value has 
probably been highly overrated, as it is now very generally 
abandoned. Dr. Ferriar, some years since, made several 
experiments with this medicine without finding the benefits he 
anticipated from its use, as it failed in the greatest number of 
instances. Although in more recent times it has been advo- 
cated by some French practitioners, yet the hazards attending 
its use far overbalance the advantages. Very alarming effects 
sometimes follow its employment, such as colic, hyperca- 
tharsis, vertigo, inflammation of the mucous lining of the throat, 
stomach and intestines ; and even death has ensued, where its 
proper dose has been a little exceeded. 

Since the powerful effects of iodine have been known, it is 
the principal, if not the sole tonic on which reliance has been 
placed, in the treatment of this and other scrofulous affections, 
although in the mesenteric disease experience has not so fully 
proved its efficacy as in other forms of the scrofula. The objec- 
tions to its use have been, that it so easily excites the mucous 
membrane of the intestines to inflammation, and aggravates it 
when such a condition exists. The form in which it has been 
found most beneficial is that of the tincture of the hydriodate 



318 DISEASES OF CHILDREN. 

of potash, in doses of from five to ten drops, to young children, 
as already mentioned, when speaking of scrofula. Guersent, 
on the contrary, says, it is totally inefficient in the affections of 
the mesenteric glands ; with the remark, that it is to be more 
cautiously used, from the fact that an active inflammatory state 
of the bowels may be more easily induced in this than in other 
forms of scrofula. The observations already made on this subject 
in the preceding article, will be applicable to the present disease. 

RICKETS. 

The name rickets is derived, it is said, from the Greek 
word pa X i Si the spine, from the curvature of this part of the body. 
Dr. Good, however, doubts this etymology, believing that, as 
the disease was first observed in England, it received its name 
from the Saxon rick or ricg, signifying a hump. This idea is 
the most probable, as the Greek term is not to be found in 
any of the Greek or Roman medical works. 

It has been supposed that this, in common with other dis- 
eases, must have existed among the ancients, but there does 
not appear any description corresponding with, this affection 
in any of the writings of the early period of medicine. Hip- 
pocrates contains no account of it as a distinct affection. It 
was probably confounded with some other disease, since we 
can scarcely doubt its existence. Homer describes the de- 
formed and hunch-backed Grecian, Thersites, in his account of 
the siege of Troy. And the no less celebrated Tyrtseus, the 
poet, of whom Horace speaks, was sent in derision to the Lace- 
demonians, when the oracle promised success to the arms of 
the latter on their obtaining a celebrated general from Athens. 
Other allusions exist in various ancient authors in relation to 
deformed persons, which prove a disorder of the osseous sys- 
tem, corresponding with that now known as the rickets. 

The first description of the disease was given by GJ ssoi| in 
1650. He states that it first appeared in England, in 1620, 
whence it spread over Europe.* 

Etiology. — This disease may be developed at all ages, but 
children are most predisposed to it. Some have asserted 
that it is never formed until after birth, and others have stated 
that it does not make its appearance until the age of two 
or three years ; but Pinel has dissected a foetus, and pre- 
served the skeleton, in which the disease was fully developed.f 
Children, at all ages, are far more subject to the disease than 
adults ; and from its being also found in the foetus, is one of the 

* De Rachiti de sive Morbo Puerili Tractus; Lond. 1650. 
t Capuron, Malad. des Enf., p. 421. 



EXCERNENT SYSTEM. 319 

evidences of the influence of the developement of the body in 
the formation of disease. The subject will again be referred to, 
under the head of the pathology of rickets. 

It has been supposed to be contagious, but there exists no 
proof of its propagation in this manner ; the idea has probably 
arisen from its being one of the complications of scurvy, scro- 
fula, and syphilis. Although not contagious, it appears to be 
hereditary, like other diseases affecting the nourishment of the 
body. 

With respect to the exciting causes, some have denied their 
existence altogether, and assert that it arises spontaneously 
from a simple natural impulse. But most practitioners are of 
a different opinion, and refer the formation of the disease to 
the action of various causes acting on the hereditary predispo- 
sition. These are chiefly such as tend to produce a debilita- 
ting effect on the general system, as impure and confined 
air, that is rarely exposed to the influence of the sun, and is 
consequently loaded with moisture. It is peculiar also to some 
climates, and prevails more in the valleys of the Pyrennean 
mountains, than it does, from all the accounts we receive at 
the present time, in Great Britain. It has also been found in 
Chinese Tartary. Although occasionally seen in the United 
States, it may be considered as of rare occurrence. With these 
may also be classed the want of nutritious food and regular 
exercise, and the absence of cleanliness, so common among the 
poor. 

In some instances, however, there appears to exist no actual 
cause for its appearance, other than the natural process of de- 
velopement, with an imperfect supply of the proper materials 
for the growth of the osseous system. It has occurred in fami- 
lies where every thing necessary to comfort and health existed ; 
one child, perhaps, out of several, exhibiting the morbid deve- 
lopement of the bones. 

In those of a scrofulous diathesis, an injury done to the bone 
by changing the vital action of the part, has produced the dis- 
ease. An example of this is given by Chaussier, in the case of 
a man thirty years of age, who received a violent blow on one 
of the parietal bones ; and also of the alteration in the bones of 
the carpus, from a severe fall on the part. 

Other causes have been charged with the production of the 
disease ; as the presence of worms, acidity of the stomach, 
dentition, etc. ; but these are probably only accompanying 
affections, aggravating the existing disorder. 

Semeiology. — The progress of the disease is very gradual, 
and almost imperceptible at its commencement. The skin is 



320 DISEASES OP CHILDREN. 

soft and flaccid, and the complexion fair and delicate, while a 
general appearance of debility occurs. The child is indiffer- 
ent to occupation of any kind, and languid ; and being indis- 
posed to exert his limbs, lies for the most part in bed. The 
digestion is evidently deranged, as appears from the acid odour 
of the breath, and the irregularity of the stools. 

The head is the first which exhibits the effects of the diseased 
condition of the osseous system ; not only in its enlarged size, 
but also in the separate state of the sutures. The neck at the 
same time becomes slender and flexible, while the jugulars 
appear more prominent. 

If the disease be not arrested at this period, the epiphysis of 
the bones appear more enlarged than in a healthy state, while 
the limbs themselves, from the emaciation, are much smaller. 
The sternum becomes softened and convex, and the ribs flat- 
tened, while their articulating extremities are increased in size. 
All the bones are softened, the limbs are unable to support the 
body, and the spine becomes distorted. If the disease continue, 
the pelvis, also, is softened and crooked, materially impeding 
the action of the bowels. 

The progress of the disease is not confined to the bones 
solely, for in very severe cases the liver, spleen and mesenteric 
glands become tuberculated ; hydrocephalus, hydrothorax and 
ascites take place, and the child, at same time being greatly 
emaciated, presents a hideous spectacle of deformity. A col- 
liquitive diarrhoea ensues, which soon terminates in death. 

These extreme symptoms are rare among the native inhabi- 
tants of the United States, but may at times be seen in some of 
the wretchedly indigent emigrants ariving on our shores. 

Pathology. — A marked deficiency of earthy matter in the 
bones, which is diminished about one half, characterizes the 
disease. It is usually connected with other evidences of scro- 
fula, and, consequently, the two diseases are essentially the 
same, but manifested in different parts of the system. They 
both depend on the supply of imperfectly elaborated materials 
for the proper and healthy growth of the body. The different 
ages at which the various forms of scrofulous diseases appear, 
afford a remarkable illustration of the predisposition to disease 
from developement. The tubercular disease of the lungs rarely 
appears before the age of puberty, for these parts undergo but 
little change from their state as it exists immediately after birth. 
Their condition appears to vary but little at any age, and therefore 
they are not liable to those alterations with which they are so 
often affected, until the period of puberty, when changes occur 
in the vocal organs, or the repeated exposure to other exciting 



EXCERNENT SYSTEM. 321 

causes, develops the latent disease. Again, scrofulous disease* 
properly so called, which is manifested in the enlargement and 
alteration of the lymphatic glands, appears at an earlier period 
of life, while the demand for nutrition keeps the lymphatic sys- 
tem in a state of preponderance. At this early period, also, the 
scrofulous diathesis will be exhibited in the ultimate tissue, the 
seat of interstitial growth, in those parts which undergo great 
changes in their structure during their growth. The bones, 
therefore, will soon manifest this, inasmuch as they are, at first, 
nearly cartilaginous, and requiring a continual deposit of earthy 
material in increased proportions ; a defect in the supply, or in 
the proper elaboration of the materials supplied, is soon mani- 
fested in an imperfect developement of the bones, constituting 
the disease in question. The growth of the bones, therefore, 
requiring, as they do, a supply of different materials, and the 
defect of the proper nutrition from constitutional causes, exhibit 
the predisposition to disease during the changes attendant on 
growth. 

Treatment. — There is but little to add on this subject to 
what has already been said when speaking of scrofula. As de- 
bility and languor characterize the disease, every attention 
should be bestowed on invigorating the system, principally by 
means of exercise, pure air, and a good and substantial diet/" 

In order to relieve the head from the supposed engorgement. 
it was formerly the practice, from the recommendation of 
Glisson, whose work is remarkable for its accuracy in the ac- 
count of the disease, to cauterize the part between the second 
and third cervical vertebras. But this remedy appears to be 
not only useless, but injurious, in a disease independent of any 
internal congestion, and where continual and increasing debility 
is one of the essential symptoms. 

Among the remedies which have been long in use, and which 
was so indiscriminately employed in children, both in sickness 
and health, in former times, is the cold bath ; a remedy 
strenuously urged by Floyer, but whose partiality for it has 
led to its too general employment in young children, where 
the abstraction of heat is often attended with great danger to 
their lives. In rickets, which is characterized by a general 
debility, the good effects of cold bathing are evident in the 
increased energies of the nervous and circulatory system. Sea 
bathing has the advantage of the tonic effects of the salts, in 
solution on the cutaneous vessels, and the stimulating effects 
of the cold Water. Whenever a child is to be submitted to 
the influence of cold bathing, it should be done by gradually 
accustoming it to an increase of temperature, commencing 
with tepid water. After being immersed in the bath, the 

41 



322 DISEASES OF CHILDREN. 

surface of the body should be wiped dry, and the child wrapped 
in flannel, and, as soon as dressed, should be allowed to take 
freely such exercise as it is capable of using. The child may 
also in the same manner be accustomed to cold effusions, which 
may be employed with perfect safety, if caution is at first used 
to have tepid water, and gradually lessening its temperature. 
Frictions are of great service after removal from the bath, and 
should in every instance be employed. 

A vast number of remedies have been used at different times ; 
it is unnecessary to mention them, for the principles of the 
treatment will be found in the preceding article on scrofula. 
The different preparations of iron are useful in these derange- 
ments of the digestive organs which require tonics. The 
attempt to supply the deficiency of phosphate of lime, by ad- 
ministering this substance, has never been followed by the anti- 
cipated success. The treatment, therefore, must be based upon 
the necessity of invigorating the system; and when it becomes 
necessary to use tonics internally, those must be selected which 
produce the least irritability. Iron, as recommended by Boyle 
and Cullen, is the best for this purpose. In rickets, therefore, 
after a preliminary aperient course, and the adoption of the 
obvious hygienic measures, if the disease still persists with evi- 
dent debility and a leucophlegmatic state of the system, iron, 
by imparting energy to the system, will exert a salutary 
agency. Iron tilings may be given where chalybeates are 
indicated, in the dose of half a grain to two grains three times 
a day, to children under two years, and from two to five grains 
to children between the ages of two and four.* 

No advantage can arise from the application of any mechani- 
cal contrivance for the support of any part of the body, as 
pressure must be made on some other part, all the bones being 
in a pliant and flexible condition ; and while one part may be 
benefited, another will be rendered more deformed by the 
pressure ; besides the impossibility then existing of the child's 
using any exercise, so important in restoring the energies of 
the system. The greatest danger, during the progress of the 
disease, is the deformity of the thorax, which becomes convex 
anteriorly and flattened on the sides. By gently compressing 
the sternum, as recommended by Dupuytren, this deformity 



* T$c Ferri. Rament., gr. iij. 

Cretse, p. p. 

Oleo. Sacchar. Citr., aa. 3ss. M. 
ft. Pulvis. divid. in vi 

partes cequales. 
One powder twice a day. 



~fy Ferri. Rament. 

Pulv. Rhei., 

" Cinnamon, aa. gr. ij. 

Magn. Carb.. gr. ij. 

Sacchar. Albi.. 3ss. M. 
ft. Pulv. dent, tal.' 

Dos. No. vi. 
A powder night and morning. 



EXCERNENT SYSTEM. 323 

may be removed during convalescence. It should be done 
daily with the hand ; and the serious interruption which would 
otherwise occur to the proper motions and expansions of the 
lungs in after life will thus be obviated. 

The bed on which the child lies should be moderately incom- 
pressible. A hair mattress is the best; and if unable to walk, he 
should be carried or ridden on one, to obtain the necessary 
exposure to the air, as the ordinary method of carrying can 
scarcely, if ever, be adopted in a bad case of this disease, where 
all the bones participate in the morbid changes. Where the 
child is old enough, all reasonable measures should be adopted 
to encourage gymnastic exercises, as a means not only of 
invigorating the general system, but also of preserving the 
symmetry of the limbs. 

INCONTINENCE OF URINE. 

This is an affection of very frequent occurrence in children 
at all ages, even until the period of puberty. It affects children 
of both sexes, but it is said that girls are more subject to it than 
boys. It is one of great annoyance, and when very frequent 
and continued, is a symptom of a general derangement of the 
system, and is accompanied with other evidences of debility 
and disorder of the body, such as indigestion, emaciation, etc. 

Etiology. — A most common cause is the natural irritability 
of the bladder, which appears to exist in infants, and the want 
of voluntary power over the sphincter. The habit, also, which 
the child acquires, of exercising no control over this evacuation, 
is also a cause of its continuance for some years. This habit 
is promoted by the natural indolence of some children, who will 
not rise at night to relieve themselves when urged by the 
promptings of nature. Among the other causes producing an 
involuntary flow of urine, is the profound sleep of children, 
w T hich prevents the stimulus of the urine on the mucous coat 
of the bladder from being felt. 

This affection is in different degrees, for while some expe- 
rience it only at night, others are affected during the day as 
well as at night Those who are affected with eneuresis gene- 
rally have frequent calls to evacuate the bladder at all times. 
The urine is more copious, and being secreted in larger quan- 
tities, is the cause of the demand being so frequently made for 
its discharge. The origin, therefore, of the disorder, appears to 
be in the secretory function, and arises from a derangement in 
the action of the kidneys. 

Semeiology. — When the affection is long continued, and the 
discharge very frequent, the general health of the child is apt 
to suffer. He becomes emaciated, and loses his strength; but 



324 DISEASES OF CHILDREN. 

as age advances the natural strength improves, the untoward 
symptoms gradually disappear, and the voluntary control over 
the sphincter of the bladder is acquired. At the period of 
puberty the incontinence of urine generally disappears without 
the interference of art. When it appears to depend on an here- 
ditary condition of the nervous system, which is often mani- 
fested by a great irritability, it has occasionally lasted beyond 
puberty^-the child, on being frightened, losing his control over the 
bladder. When at other times it has been relieved, it has again 
made its appearance on the developement of the organs of 
generation, both of the male and female, when the latter takes 
place with more than ordinary vigour. This renewal of the 
disease renders it one of great obstinacy, and very difficult of 
management. 

TEEATMENT.^The causes of this affection must be the guide 
for the treatment, which must accordingly vary in different 
cases. In those arising from continuance of a bad habit con- 
tracted at an early period of life, the chief means must be 
directed to correcting it, by accustoming the child to arise 
once or twice during the night, while all late suppers are to be 
avoided. A great variety of means have been used at different 
times for the relief of the nocturnal eneuresis of children, each 
of which, although considered as infallible at the time, has been 
obliged to give place to others of no less efficacy. It is of 
importance to find some remedy for this distressing complaint ; 
for although of itself it may not be one of hazard to the future 
health or life of the child, yet, from the shame attached to it, 
and the means often resorted to, by unreflecting persons, to break 
the habit by severe chastisement or ridicule, a serious effect 
may often be made on the temper and morals of the sufferer. 

It has been attempted to be cured by the position in bed, and 
Sir Charles Bell has asserted, that the urine is only voided 
by children when lying on the back ; and that a cure may be 
effected by altering the position of the child in bed, and causing 
him to lie on the side or face. This, however, does not appear 
to be the case ; besides the great difficulty of preserving chil- 
dren in this position, which must almost preclude the possibility 
of relying on this method of cure. 

As the disease evidently depends on the increased secretion 
of urine, such remedies as experience has discovered, to control 
this increased action of the functions of the kidneys, must be 
resorted to for its relief. These are medicines possessing a 
sedative nature, combined with a tonic. An infusion of Colombo 
root, with a drop or two of tincture of opium added to each 
dose, according to the age of the child, will be a useful means 
of controlling the increased action of the kidneys. There is 



EXCERNENT SYSTEM. 325 

always more or less want of vigour in the digestive organs 
requiring some mild tonic or bitter infusion, to restore the lost 
tone of the stomach. The muriated tincture of iron has also 
been used for the same purpose ; it may be given in doses of 
from two to ten drops, largely diluted with water, two or three 
times a day. The leaves of the arbutus, uva ursa, given in the 
dose of five to ten grains, to children of five or six years, is a 
useful means of controlling the action of the kidneys ; it pos- 
sesses both tonic and astringent properties. 

Of late, the extract of nux vomica has been highly recom- 
mended by the German physicians, in incontinence of urine.* 
It is said to be more applicable to children for irritability, from 
whatever cause it may arise, as its action is confined particu- 
larly to the spinal marrow, and does not disturb the sensorium, 
like preparations of opium. This is a remedy which I never 
have tried in the affections of children, and therefore am unable 
to give any result from experience. It is too hazardous a 
remedy for so trifling a complaint. It has been given in Ger- 
many, in the proportion of a grain mixed with four ounces of 
mucilage. A teaspoonful of this mixture, every two or three 
hours, is the dose for a child from one to three years ; while the 
tincture of the seeds is applied by friction to the loins. 

A blister to the loins has been occasionally found serviceable, 
as well as the more permanent effects from the use of stimulating 
plasters, such as Burgundy pitch. The latter may be made a 
little more efficacious, by the addition of some stimulating sub- 
stance, such as camphor. 

With respect to instrumental means for relieving this disease^ 
they ought, as much as possible, to be avoided ; but in obstinate 
cases, which resist all other means, the introduction of a bougie 
or sound into the bladder will sometimes be found useful, by 
stimulating the neck of the bladder, and exciting a new action 
in the part. Instruments, however, which have sometimes been 
applied to the penis, for the purpose of compressing the urethra, 
are decidedly injurious in various ways to young children, and 
ought never to be employed. Although they may arrest the 
flow of the urine for the time, they never cure it ; and the in- 
jury done to the part, and the premature excitement they cause 
to the genital organs, are far greater than the temporary advan- 
tages resulting from their use. 



326 DISEASES OF CHILDREN. 



DYSURIA. 

Dysuria attacks children at all ages, and is one of the most 
distressing diseases of infancy, and often, like other affections of 
the urinary organs, will continue for some time without any 
suspicion of its existence. 

Etiology. — It may arise from different causes ; inflammation 
in the bladder, urethra or kidneys, or the presence of oxyures 
yermiculares in the rectum, will give rise to difficulty and pain 
in urinating. The excitement of the system during teething, 
and the derangements of the digestive organs at this time, at- 
tended with an acid state of the imperfectly digested food, will 
also excite dysuria. This condition of the digestive organs 
tends always to the formation of lithic acid, and urinary cal- 
culi is the result. Quite young children are often affected with 
calculus diseases, the concretions existing in the kidneys, 
uterus, bladder, or urethra, and they have been found lodged 
beneath the prepuce. It is well known that they consist essen- 
tially of lithic acid ; and where the mass of calculus is composed 
of phosphatic salts, the nucleus is lithic acid. 

There is a variety of dysuria which is occasionally met with, 
and which Dr. Willis, in his late work, speaks of having seen 
a few cases. It is a symptomatic form of disease, and is the 
same as described by Professor Schoenbein, under the name of 
urodialysis neonatorum.* The symptoms of this affection are 
described by him as follows : 

A very small quantity of urine is voided, and often only a 
few drops at a time ; it is high-coloured, and stains the linen 
yellow. It is evidently attended with great pain, for the little 
patients cry violently, and draw up their limbs as if suffering 
great distress. It is dependent on the condition of the diges- 
tive organs, as is evinced by the acid odour of the breath, and 
the knotty and indurated state of the alvine evacuations : it is 
uniformly attended, also, with a highly irritable state of the skin. 

Semeiology. — Distress on urinating may be suspected by the 
cries of the child, caused by the pain and tenesmus it expe- 
riences when passing urine. This fluid flows only in drops, with 
great effort. In general it is high coloured, and when the dif- 
ficulty is caused by calculus concretions, sometimes mixed with 
blood. 

When there is sand or gravel, it may be known by the de- 
posit of lithic acid, on permitting the urine to stand undisturbed 
for a short time ; the immediate causes of this deposition on 
the chemical changes spontaneously occurring in the urine, 

* Op. Cit.. p. 28. 



EXCERNENT SYSTEM. 327 

which it is unnecessary here to particularize. The precipitate 
is a brown sediment, either in the form of powder or small 
crystals. At times it is of a purple or pink colour, from the com- 
bination of purpuric with lithic acid. 

As is the case in adults, these evidences of a morbid state of 
the urine are occasionally absent, while the child is suffering 
from larger accumulations of calculus deposits. The only 
method of ascertaining the existence of calculi is with the sound, 
or perhaps they may be discovered by the finger introduced 
into the rectum. But when a calculus is arrested in the ureter, 
great suffering may exist without our being able satisfactorily 
to ascertain the cause. Children affected with calculi are very 
liable to convulsions, in the state of high sensibility in the tender 
age of infancy. 

When inflammation exists in the urethra, or neck of the blad- 
der, or in the mucous coat of the bladder itself, a quantity of 
mucous is discharged with the urine ; this symptom attends the 
urodialysis neonatorum above mentioned. In this affection there 
is much febrile action ; the skin is hot and irritable. It often be- 
comes the seat of eruptions of different kinds, either some form 
of prurigo or urticaria. At other times, the cutaneous disorder 
appears under the form of psydraceous pustules, scattered over 
different parts of the body, causing troublesome sores, especially 
in the folds of the skin. 

The symptoms of dysuria may be easily detected by a little 
attention ; for the child cries most violently when about to make 
water, and which is only voided in drops. During these pa- 
roxysms he will often carry the hand to the genital organs. 

Treatment. — The treatment should, in every instance, be 
commenced with mucilaginous drinks, emollient applications to 
the pubes, enemata of infusions of linseed of catnep; the latter 
is an excellent anodyne in painful affections of children, affect- 
ing either the lower intestines or urinary organs. The hip bath, 
also, forms an essential part of the treatment of all disorders 
affecting the urinary organs. The excitement of the system 
during teething, and the disorders of the digestive organs arising 
at this time, demand the special attention of the physician. As 
the stomach abounds in acid, the usual measures for destroying 
its excess must be employed, while close attention is paid to the 
improvement of the digestion. 

Among the alkalies, soda seems to possess the most powerful 
influence on the bladder in controlling its irritability. As the 
connection between the acid state of the stomach and bowels 
and the urinary organs, where calculus concretions are formed, 
is evident in all that are affected with the latter disease, the use 
of soda becomes a very prominent means in the treatment of 



328 



DISEASES OF CHILDREN. 



those cases of dysuria which are dependent on the formation 
of lithic acid. It not only corrects the acid in the stomach, but 
also the secretion of lithic acid in the kidneys. Where there 
is any hereditary disposition to calculus diseases, they may 
almost with certainty be prevented by the timely and constant 
use of alkaline remedies. The annexed formula may be given 
where there is much indigestion existing, and where a mild 
tonic is indicated ; it may be administered in some barley water, 
gruel, or other mucilaginous drink, three or four times a day.* 
Under other circumstances it will be necessary only to give the 
soda uncombined with any other remedial agent, either in the 
form of lozenges or solution, from three to twenty grains in the 
course of the day. The perseverance in this plan will effectu- 
ally prevent the formation of lithic acid deposites in the kid- 
neys and bladder. 

During the employment of these means, additional measures 
may be needed to influence the digestive organs, by exciting 
the secretory functions of thejiver and intestines. Calomel and 
rhubarb may therefore be given, to which ipecacuanha should 
be combined, if there is any fever. f 

It is only in the prevention of the formation of lithic acid, 
that we chiefly can expect any success by the use of these 
means. The correction of the deranged digestion, and the neu- 
tralization of the excess of acid, will therefore form the principal 
object in our treatment ; the latter especially, when the red 
crystalline deposit exhibits the predominance of lithic acid in 
the system. On the principle that diet, destitute of azote, is 
as applicable to the disease in question as an opposite course, 
is found in diabetes mellitis, M. Magendie has recommended a 
vegetable diet generally in this affection, where azote is in too 
great excess. 

A white deposit, indicating the presence of phosphatic salts, 
requires a different course of remedial agents. In such cases 
Sir William Prout recommends mineral acids, uva ursi and cin- 
chona. Muriatic acid is particularly recommended by him. 
A child from two to six years of age may take a tablespoonful 
of a mixture, composed of a scruple of acid and six ounces of 
water, three times a day. The muriated tincture of iron is also 
useful, as it combines the tonic effects of the iron with the spe- 
cific effects of the acid, which is always in excess. It may be 



* Ifc Racl. Colomb., gr. x. 

Sodae Sesquicarb., gi\ xl. 

Aquse Few., gij. M. 
A teaspoonful three or four times a 
day. 



t ~fy Pulv. RheL, gr. vi. 
Hydr. Subrn., gr. it. 
Pulv. Ipecac, gr. j. M. 
Divid. in pulv. No. iv. 
One twice a day to a child four years 
old. 



EXCERNENT SYSTEM. 329 

given diluted with water, fifteen drops to two ounces — a tea- 
spoonful, three or four times a day, to a child of the same age. 
Anodynes, in such cases, are also indispensable, and may be united 
with tonics. As in other diseases of children, attended with 
great irritability, Dover's powder is one of the most useful 
forms in which opium can be administered. Where it is ne- 
cessary to keep the bowels open, the neutral salts should be 
substituted for magnesia and other alkaline purgatives ; this 
may be rendered somewhat more efficient by the free use of 
diluents. 

RETENTION AND SUPPRESSION OF URINE. 

Retention of urine is an affection which Dr. Dewees remarks 
is more frequent than is supposed, and that some infants have 
perished from this cause without its having been suspected. 
Immediately upon the birth of the child, the effects of the im- 
pression of the air upon the surface of the body are apparent, 
as well as on the mucous membranes exposed to its influence. 
The nares and bronchial passages both give evidences of the 
excitements they experience from the stimulating influence of 
the cold air ; and the bladder, from its sympathy with the skin, 
is one of the first organs to contract and repel its contents. 
Although one of the first excretions, yet it sometimes happens 
that the urine does not flow for some days after birth. 

Etiology. — The obstruction to the passage of water may 
arise from spasm at the neck of the bladder, or congenital in- 
flammation of this part, or of the rectum ; or from the clogging 
of the urethra by inspissated mucus. Besides these causes, in 
the first days of infancy, the irritating qualities of the mother's 
milk may become a cause of this affection ; or, during the pro- 
cess of teething, when the teeth protrude with difficulty, a 
retention of urine may arise. 

Semeiology. — From whatever cause it arises, the child 
evinces great distress on attempting to urinate, and cries vio- 
lently at such times, while it appears continually to suffer from 
some pain. In older children there will not be so much diffi- 
culty in ascertaining the nature of the suffering, but in young 
infants it is often a matter requiring close attention to ascertain 
the cause of the distress. As it is a disease of great danger, 
the condition of the diapers should be carefully examined, 
whenever a young infant suffers great pain and cries much. 
No reliance should be placed on the representation of nurses 
that the urine is regularly discharged, unless they positively 
state that it is found regularly wetted. When the disease is sus- 
pected to exist, the abdomen and pubic region should be ex- 

42 



330 DISEASES OF CHILDREN. 

amined ; they will generally be found tender, very painful, and 
much swelled. 

Where retention has existed for some time, fever arises, the 
skin becomes hot, a determination of blood takes place to the 
brain, and convulsions and death ensue, even when its cause 
has not been suspected. 

Treatment. — -Where it arises immediately after birth, its 
cause is frequently the existence of a little mucus clogging up 
the urethra, and which may be removed with a small probe. 
Fomentations with hops, or a flannel dipped in warm water, 
may be applied to the pubic region ; or frictions may be used 
over the affected part with camphorated oil, which will often 
relieve the spasm of the neck of the bladder. If these are 
ineffectual, the whole system must be relaxed by immersing 
the child in a warm bath ; an enema of warm water alone is 
also a useful adjunct to the other measures. 

If these means fail to procure a flow of urine, no time should 
be lost in resorting to the use of the catheter, the only effectual 
method of relieving retention of urine. A small sized flexible 
catheter should therefore be introduced into the bladder, which, 
in a young infant, it is scarcely ever necessary again to use. 

If the fever continue, and cerebral oppression arise, a couple 
of leeches applied behind each ear may be necessary to relieve 
the congestion, and prevent the occurrence of convulsions. 

With respect to retention of urine arising in children that are 
teething and sucking, the evident exciting cause will sufficiently 
point out the remedies which are applicable to such cases. 
The mother should use diluent drinks, and avoid all stimulating 
aliments which impart an irritating quality to her milk. 

If, on examining the hypogastric region, the bladder be found 
empty, which may be suspected when there appears to be no 
swelling or pain in the part, there is then doubtless a suppression 
of urine. This disease, anuria, arises from a defective action 
of the kidneys, and it occasionally happens that this function is 
not exercised for twenty-four or even forty-eight hours after 
birth ; not having been established. It appears to arise from 
a congenital paralysis of the kidneys. Retention of urine may 
also arise from congenital deformity of the male in the uretha. 
This passage is sometimes entirely absent, and is usually 
accompanied with other deformities in the anterior portion of 
the bladder and parietes of the abdomen. Congenital hypos- 
padias, where the urethra passes a short distance along the penis, 
and opens on its lower surface, may exist. The orifice of the 
urethra is also sometimes simply closed ; an incision may in 
this case be made, and the part kept from uniting by means 
of a tent, or a small piece of gum-elastic catheter. 



EXCERNENT SYSTEM. 331 

Treatment. — The means to be resorted to in the treatment 
of suppressed urine, are such as will excite the secretory action 
of the kidneys by a direct influence on these organs : such as 
an infusion of parsley root, apium petroselinum, with a few 
drops of sweet spirits of nitre. In ordinary cases this will 
generally succeed in relieving it, while enemata and the warm 
bath are at the same .time used. The latter is especially 
beneficial in all the forms under which the disease appears. 
In this affection mild diluents should take the place of any 
excitant to the kidneys, whenever fever is present; and in any 
form of the disease when there is evidence of inflammatory 
action in the affected part, leeches should be applied to the 
lumbar region. 

DIABETES. 

Diabetes is usually divided into two species ; diabetes insipi- 
dus and diabetes mellitus. The former, which corresponds 
with the hydruria of Dr, Willis, in his recent work on the sub- 
ject of the diseases of the kidneys,* is characterized by the 
simple, increased quantity of urine, independently of any in- 
creased action of these organs, from imbibing largely of some 
watery fluid. The other species, or melaturia, as it has been 
recently called, is distinguished by a quantity of saccharine 
matter in the urine, which is also very greatly increased in 
quantity. Both these forms affect children ; the first mentioned 
is that which is most frequent. 

There is another variety which may be classed with the in- 
sipid form of diabetes ; this is where the copious discharge is 
attended with a deficiency of urea, and described by Dr. Wil- 
lis, by the name of anazoturia, from the absence of the azotic 
principle of the urine. This is the form of the disease which 
he observes has been so often reported as cured, and is the kind 
most frequently occurring among the children of the poor, who 
suffer greatly from privation of both food and air. 

In treating of this disease, the name so long used to designate 
an excessive secretion, will be retained ; and although it is more 
philosophically correct to disunite that form in which the urine, 
although in excess, still retains the proper proportion of its solid 
ingredients, from that in which it is destitute of one of them, 
yet the distinction is one which it is sometimes difficult to make ; 
while the term diabetes is applicable to inordinate secretion, 
and frequent evacuation of urine, attended with great emacia- 
tion and debility, whether the urine is deficient in its compo- 

* Urinary Diseases, and their Treatment, by Robert Willis, M. D. ; London, 
1838. 



332 DISEASES OF CHILDREN. 

nent parts, or whether it is, on the other hand, characterized by 
the remarkable additional qualities it acquires in the saccharine 
form. Besides, it will be more suitable to the nature of the 
present treatise to treat the subject in a more general sense ; as 
it can scarcely be considered the peculiar object of this work 
to enter into a discussion of the nature of such diseases as are 
common to all ages. A concise view of the subject, with refer- 
ence to its occurrence in children, and any remarkable aspect 
it may assume, or treatment it may require on this account, is 
all that can be expected in a work devoted exclusively to the 
diseases of children. For more particular information, there- 
fore, as to the pathology of diabetes, and the distinctions which 
modern science has made in the various renal affections, other 
and more elaborate works may be consulted. 

As occurring in children, diabetes was first noticed by Mor- 
ton, in 1694,* and described much more recently by Vena- 
bles,f whose observations are exceedingly valuable with refer- 
ence to the disease in children. The last mentioned of these 
writers, as well as others, have noticed the two kinds ; but all 
agree that the insipid diabetes is the most common in early 
life. 

Etiology. — As to the predisposition to the disease, it is in 
some instances hereditary, as several members of a family, and 
their descendants, have been known to be affected with it ; and 
it frequently occurs in those of a scrofulous habit, although not 
confined to them. It has been remarked that phthisis has not 
unfrequently both preceded and accompanied diabetes ; and 
that there is scarcely an instance of this disease existing among 
adults, that is not attended with some pulmonic affection. It 
has been noticed to alternate with it, and the symptoms of 
phthisis have for a time been suspended ; and on the tempo- 
rary relief of the diabetic symptoms, the tubercles have become 
fully developed, and have passed through their various stages, 
and terminated in the death of the patient. It therefore ap- 
pears in some measure connected with the imperfect assimila- 
tion in the ultimate tissues, occurring in the scrofulous habit. 

The ordinary exciting causes appear to be exposure to sud- 
den vicissitudes of the weather, and the use of improper and 
badly prepared food. Experiments on the lower animals prove 
the influence of a certain species of diet on the urinary secre- 
tions. Dogs and rabbits fed on rye meal, or exclusively on 
wheat flour, become greatly emaciated, while diabetes insipidus 

* Phthisiologia, sive Exercitationes de Phthisi., by Richard Morton, M. D. ; 
Lond. 1694, 
t A Practical Treatise on Diabetes, etc., by R. Venables, M. D. ; Lond.1825. 



EXCERNENT SYSTEM. 333 

is produced. It is also known to arise with the changes in 
the system occurring during the period of dentition, produced 
probably by the changes which occur at this time in the func- 
tions of the digestive system. Teething adds to the general 
irritation in this as well as in other diseases. 

Semeiology. — Dr. Dewees remarks, that he has never seen 
children affected with it after the fifteenth month. It is most 
liable to occur about the period of weaning, as would be sup- 
posed would be the case, when it is considered how intimately 
it is connected with diet. This remark is applicable, of course, 
to infants, for the disease occurs at all ages ; and pure diabetes 
mellitus has been noticed from the age of three years to twelve, 
including also the period of infancy. 

For the most part it is very insidious in its approach, and 
emaciation and languor exist for some time before the cause is 
suspected. If the increased discharge of urine be at all re- 
marked at first, it is scarcely regarded as a disease, and much 
time is necessarily lost before proper treatment is instituted. 
The languor and emaciation, which are prominent symptoms 
of the disease, steadily increase from the great loss of the 
solid matter of the body ; for experiments show that although 
the thirst is very great, yet the quantity of urine passed far ex- 
ceeds the fluids taken by the mouth. As the disease advances, 
the skin becomes dry and flabby, the little patient is feverish and 
fretful, and excessively prostrated. At first, the alvine evacua- 
tions are not much altered from their natural condition, but with 
the progress of the other symptoms, they also become greatly 
deranged, showing a. great alteration in the secretions of the 
liver and intestinal surface ; the former exhibits an increase in 
the bilious discharge, while the latter show a slimy and inspis- 
sated state of the mucus, furnished by the muciparous follicles. 
Among the abdominal symptoms, is the increasing enlargement 
and tenseness, while the steady emaciation presents a strong 
contrast, resembling, in this respect, the progress of the mesen- 
teric disease. 

The circulation, which at first is but little affected, becomes 
more excited; the pulse is quickened, and is afterwards weak 
and small, while a considerable degree of fever exists as the dis- 
ease advances. 

As in the adult, these symptoms are attended with an exces- 
sive discharge of urine, and the desire for passing it is incessant. 
Dr. Francis informs me, that in a case which occurred to him in 
a child aged twenty months, six pints were discharged in the 
course of twenty-four hours, for several days. Dr. Mott* re- 

* Amer. Med. and Philosoph. Register, vol. i. p. 347. 



334 DISEASES OF CHILDREN. 

corded the case of a boy aged nine years, who voided from 
nine to ten pints daily, of a clear limpid urine, very sweet to 
the taste. The light limpid colour is characteristic of the 
urine destitute of its urea, the azoturia of Dr. Willis. The 
non-existence of urea may be ascertained by evaporating a 
portion of urine, when it will scarcely leave a residuum. In 
urine still retaining this essential property, it will evaporate to 
the consistence of a thick syrup, which, on cooling, concretes 
into a crystalline mass. This will be sufficient to ascertain the 
fact, if any doubt should exist, without proceeding further with 
the analysis. The thirst is generally proportioned to the quan- 
tity of urine discharged, but usually exceeds the quantity 
taken. It is a very distressing symptom, and one which, in a 
young child, might easily be disregarded. Although, for the 
most part, the urine is clear and limpid, yet its colour and con- 
sistency are different in different cases ; for in some it deposits 
white sediment, in others it is of a straw colour, while in some 
instances it is green. 

One remarkable symptom exists in this disease in children; it 
is the strong tendency to cerebral effusion, preceded by all the 
usual symptoms, such as pain in the head, throbbing of the tem- 
ples, and other evidences of cerebral congestion. When it has 
long continued, its termination is in effusion in the brain ; and the 
disease, from inattention to the original affection, is regarded as 
primarily hydrocephalus. 

Morbid Anatomy and Pathology. — The most careful anato- 
mical investigations have thrown but little light on the nature 
of diabetes. Almost every morbid condition has been disco- 
vered in those who have died from this affection of the kidneys. 
The stomach has been found enlarged, and its vessels greatly 
dilated. The lymphatic system of the abdomen, also, more than 
usually developed. Tubercles have been found in the lungs, 
and various other morbid changes, which appear to have arisen 
from the long continuance of a violent constitutional affection, 
and were, to appearance, more the consequence than the cause, 
such as deposits of coagulable lymph, and serous effusions in 
the cellular tissue. The kidneys are the parts more frequently 
found in a morbid state than any other of the abdominal viscera. 
They are, in general, enlarged, and the blood-vessels leading 
to them turgid ; the renal capsules firmer and harder than usual, 
while the substance of the kidney itself has undergone some 
organic changes. They have presented the granular or mot- 
tled state described by Dr. Bright, as occurring in cases of 
albuminous urine. 

Although these alterations have been found, there are other 
cases in which no change was discovered in the size or struc- 



EXCERNENT SYSTEM. 335 

ture of the kidneys, for both were of the same size and form, 
and differing in no respect from the state of the kidney in 
health. In all cases, however, the blood-vessels leading to 
them are large and turgid with blood. No alterations have 
been found in the nerves going to the kidneys. The ureters, in 
some instances, are enlarged, as well as the bladder, and in 
others contracted. In some cases, no departure from the 
normal condition has been discovered. It appears that all the 
alterations discovered in the kidneys are referable to a long 
continuance of morbid action in them. The liver is usually 
found congested. 

The nature of the disease has not been satisfactorily ex- 
plained by any pathologist, and it still remains one of the most 
obscure ; for anatomical investigation has not, as yet, presented 
it in a form whereby we can direct our practice. The only 
approximation to the truth is to be found in the disorder of the 
digestive organs, and that the disease primarily exists in the 
deranged functions of the stomach. 

The experiments recently made by Dr. Bouchardt,* go very 
strongly to prove the origin of the disease to be in the impaired 
digestive function. One of the most prominent symptoms is ex- 
cessive thirst, and is always in direct proportion to the quantity 
of farinaceous or saccharine aliment taken ; these being dimin- 
ished, the quantity of sugar decreases. Farinaceous food forms 
fecula or starch, in the deranged condition of the digestive 
organs just mentioned. Sugar is formed from fecula precisely 
as it is in the laboratory of the chemist, and during the trans- 
formation requires to be dissolved, when seven times its weight 
of water is necessary for the solution. Hence the great demand 
for water in this disease. 

The other form of diabetes, in which the urine is insipid, but 
destitute of urea, appears to arise from a similar derangement of 
the digestive organs, whereby a full elaboration of the nourish- 
ment is not effected. Urea having been found to exist in the 
blood, must be formed during the process of digestion. 

Treatment. — From the few facts which have come to our 
knowledge, as to the pathology of diabetes, the treatment is 
founded. The precise changes in the kidneys are unknown, 
but that a disorder of the digestive functions exists, is a well- 
established fact. As in both forms it is dependent on the condi- 
tion of the digestive organs, these must receive our first atten- 
tion. It has been seen that both diabetes insipidus and the 
mellitic variety are produced by farinacious food ; the first 
step in the treatment, therefore, is to withhold such food as ex- 

• Revue MSdicale, Juin, 1839. 



336 DISEASES OE CHILDREN. 

j 

perience has proved to be one of the main causes. For the first 
suggestion of this fact in the treatment of diabetes, the profes- 
sion is indebted to Dr. Rollo ; and his views have been fully 
confirmed by repeated experiments on the lower animals, and 
by the investigations of chemical philosophy, as well as by the 
favorable result of the practice. 

The most appropriate kind of animal food for children is 
milk, which should be liberally used, and alternated with light 
broths. The latter, however, may be dispensed with when 
there exists much heat of the surface. The bowels should be 
kept open by mild aperients, and rhubarb and aloes, from their 
tonic effects, are the best that can be employed. The rhubarb 
may be given in infusion, as the taste may be concealed more 
easily in this form than in any other.* After the operation of 
this, some anodyne should be administered : opium, however, 
with great caution, owing to the strong tendency to cerebral 
congestion in children affected with this disease. Hyoscyamus, 
from its salutary action in not accelerating the pulse, is better 
for those cases in which there exists fever, than opium, besides 
the advantage gained from its not increasing the tendency to 
fulness of the blood-vessels of the brain. The proper dose of 
hyoscyamus is a quarter of a grain, for children within the 
year ; older children may take a half to one grain, three or 
four times a day. The only form in which opium is admissible 
in this disease, is Dover's powder ; a grain of which may be 
given two or three times a day to a child two years old. 
During the use of these means the skin should be kept excited 
by the Warm bath, or by the use of a flesh brush ; a very im- 
portant measure in all diseases of the kidneys, and every case 
of diabetes is accompanied with an irritable condition of the 
skin. 

Among the remedies which have been used for the relief of 
diabetes in children, and in the hands of M. Venables with 
success, is the phosphate of iron ; it is both astringent and 
tonic in its operation, and therefore useful in this disease, where 
its employment is not counterindicated by the febrile action 
of the system. It may be given in doses of from two to three 
grains to children aged between one and three years, and from 
five to ten grains to children from four to seven. 

On the appearance of any inflammation in the kidneys, 
leeches should be applied to the loins, and the ordinary measures 
adopted for the purpose of combating inflammation. 

* Ifc Infus. Rhei., gjss. 

Tinct. Cinnamon., 3ss. 
Syrup. Simpl., §ss. 
Tinct. Aloes Comp., 3j. M. 
One or two teaspoonsful every three hours. 



EXCERNENT SYSTEM. 837 

In the simple form of diabetes, known as the disease termed 
azoturia, bitter infusions, with alkalies, have been found the 
most beneficial, by Yenables, Prout and Willis. An infusion 
of gentian or Colombo, with the sesquicarbonate of soda, will 
be found useful, while mild anodynes, as already mentioned, 
are used. Dr. Dewees advises spirits of turpentine applied to 
the clothes in such a manner as to create an atmosphere of 
trebinthinate vapour around the child ; in this manner he has 
cured several cases. From the successful results which have 
followed the internal use of iodine, made after the formulae of 
Lugol, and also from the administration of the hydriodate of 
potash, in three obstinate cases of the mellitic variety, which 
occurred in adults in the practice of Dr. Francis, the employment 
of this new remedy promises advantages which will probably 
lead to its more general use in this disorder. 

During the period of teething it will be necessary to examine 
the gums, and cut them, if the teeth appear to be pressing upon 
them, and thus take off one source of irritation on the system. 

CUTANEOUS DISEASES. 

The great multiplicity of cutaneous diseases, their different 
causes, and the almost endless variety of their appearances, 
render a proper classification of them necessary, that they may 
be advantageously studied and properly treated ; for without 
some distinctions, founded either on their pathology or cause, 
or on both combined, it is in vain to expect to possess any 
correct principles for their management. 

The first attempt at classification appears to have been made 
in 1585, by Mercurialis,* who separated those diseases which 
affect the scalp from such as exist on other parts of the body. 
Turnerf adopted a similar division, from remarking an essentia] 
difference in the treatment necessary in those affections occurring 
in parts covered with hair, and in other parts of the tegu- 
mentary surface; he also referred to the causes as a good 
basis for their classification. Lorry ,J in 1777, in his work on 
the same subject, maintains the same views, with some modi- 
fication. Plenck afterwards arranged cutaneous affections 
according to their appearances, without taking into consideration 
their etiology, or rather rejecting it altogether. || Willan and 



* De Morbis Cutaneis. Venet. 1572. 

t A Treatise on the Diseases Incident to the Skin, by Daniel Turner, M. D.; 
London, 1714. 

X Tractatus de Morbis Cutaneis; Paris, 1777. 
II Doctrina de Morbis Cutaneis, J. J. Plenck; Vien 1783. 

43 



338 DISEASES OF CHILDREN. 

Bateman's classification is based on the same views,* which are 
also adopted by Alibert and Rayer, who have greatly multiplied 
the number of affections incident to the skin.f 

Plumbe, in his able work on this subject, has considered 
more the cause of these affections, and in his classification has 
referred to the influence of the constitutional condition in giving 
origin to them, or modifying their character and progress; 
unquestionably the only safe course to proceed with reference 
to these diseases, which are more frequently symptoms of 
the existence of other morbid affections ; and he justly remarks, 
that there can be no correct arrangement for practical purposes, 
in which the constitutional causes do not form some portion.^ 
The same view has been adopted by Dendy, and applied by 
him to a much larger number of these diseases than is embraced 
in Plumbe's treatise.|| 

All the existing arrangements of these diseases are still evi- 
dently imperfect ; and one based on scientific principles, which 
may be made practically applicable, is still a desideratum. 
The difficulty, however, of this part of the subject is acknow- 
ledged by all to be very great. A want of accuracy and pre- 
cision exists in all the systems, founded either on the patholo- 
gical conditions of the part, or on the external appearances of 
these affections. If, on the one hand, the ^pathological altera- 
tions of the parts be taken as the basis of the classification, the 
difficulty at once meets us in the fact, that it rarelyhappens 
that one tissue alone is affected through the course of the dis- 
ease ; others become involved, offering a complication of the 
original affection, in the pathological alterations of other por- 
tions of the cutaneous system. Again, if the phenomena they 
present be taken as the groundwork, a similar difficulty will be 
found to exist, for the reasons just mentioned. Although great 
skill and singular accuracy has been exhibited in the pictorial 
delineations, yet as the appearances change, not only from the 
natural course of the disease in one tissue, but likewise from 
its involving other portions of the cutaneous system, whereby 
a disease, with the well marked appearance of one genus, may 
present that of another in the course of its progress, it is evi- 
dently not safe to rely on an arrangement so arbitrary and 
artificial. 



* Description and Treatment of Cutaneous Diseases, by R. Willan, M. D. ; 
Lond. 1805. A Practical Synopsis of Cutaneous Diseases, by Thomas Bateman, 
M D.; Lond. 1814. 

t Description des Maladies de la Peau, par J. L. Alibert; Paris, 1814. Trait€ 
Theorique et Pratique de la Malad. de la Peau, par M. Rayer; Paris, 1826. 

t A Practical Treatise on the Diseases of the Skin, etc., by Samuel Plumbe; 
London, 1824. 

ii Practical Remarks on the Diseases of the Skin, etc., by Walter C. Dendy, 
Surgeon, etc.; Lond. 1837. 



EXCERNENT SYSTEM. 339 

Difficulty also attends the more recently revised system of 
arranging them according to their etiology ; the same disease 
being at times produced by different causes. A system found- 
ed, both on the anatomy of the skin, with the seat of the mor- 
bid changes occurring in it, and the influence of external and 
internal causes in the production of these morbid changes, 
appears to be the correct and only one for practical purposes 
which could be adopted. The subject is one almost, if not 
altogether, impracticable in the present state of science. An 
increased attention, however, to the anatomy of the skin, has 
been manifested within a few years ; a subject which affords 
a better opportunity for the successful culture of the knowledge 
of morbid conditions now under consideration, than can be 
derived from the simple inspection of the diseased part, uncon- 
nected with its state in health. The recent works of Breschet, 
Yauzeme and Gurlt, on the anatomy of the skin, may be re- 
garded as highly important in directing the investigation of the 
diseases of the skin, to the state of the various parts of this 
complicated structure — the seat of several important functions — 
in its normal condition. 

Without pretending to be able to simplify a subject which 
has baffled the genius of many distinguished men, I shall con- 
fine myself principally to the consideration of the causes of 
cutaneous affections of children, inasmuch as it appears to be 
more usefully applicable in their treatment, than an arrange- 
ment founded on their external appearance. It is to their 
causes, therefore, that the arrangement here proposed will 
chiefly be directed. 

The pathology of these affections w T ill also be considered in 
a general manner, in connection with the etiology, as a guide 
for the arrangement ; which will be such a modification of the 
existing systems, as experience justifies in considering the best 
applicable to their management. 

General Etiology. — The first of the predisposing causes 
is the hereditary conformation of the skin. Besides the actual 
alterations in its condition, exhibited in the existence of ncevi 
materni, congenital spots, and malformations, these parts, as 
well as others, participate in the molecular changes arising 
from the transmission of peculiarities in the process of nutrition. 
Hence we find the obstinate diseases, which occur in those 
who inherit a scrofulous diathesis, and also the eruptions on the 
surface, arising from the transmission of syphilitic affections. 

But independently of this, there are those who are born 
with an extremely irritable state of the skin, although no such 
morbid condition could be found to exist in their parents. The 
latter are remarkable for their robust health, and transmit to 



340 DISEASES OP CHILDREN. 

their posterity that abundance of vitality, which greatly dis- 
poses those parts that are exposed to the immediate action of 
exciting causes, to pass into a morbid condition. Very severe 
inflammations have occurred under such circumstances, show- 
ing the predisposition to disease abounding in a part, in a high 
state of vitality and developement. 

The abundance of blood in the tegumentary tissues of an in- 
fant, imparts a strong predisposition to inflammatory affections, 
easily excited ; hence the early appearance of an eruption, on 
the application of a very slight degree of their ordinary exciting 
causes. M. Valleix describes a species of pustule, occurring 
in new-born children, which appears to depend on the ordinary 
state of vascular excitement or congestion natural to children 
at this age. These pustules are usually mistaken for a conge- 
nital syphilitic affection, from their early occurrence; this opi- 
nion he conceives to be erroneous, from the frequent mildness 
of the disease, and other circumstances connected with its rapid 
disappearance without the interference of art. 

From the same cause many children are affected from birth 
with an inflammation of the sebaceous follicles, producing a 
disease of the most remarkable obstinacy. 

Although diseases of the skin generally may occur in any 
class of persons, and under a variety of circumstances of con- 
stitutional and local derangement, yet they are most likely to 
take place where there is an enfeebled state of the capillaries of 
the skin, exhibited in the irregular and imperfect action of the 
functions of this part, especially in children advanced beyond 
the period of infancy, where the normal action assumes more 
the characters which are peculiar to the state of the adult. 
Whenever there exists a want of uniformity in the proper 
action of the part, as appears from the irregular action of the 
sudatory glands, the cutaneous secretion being easily excited or 
suppressed, there is a much greater liability to cutaneous dis- 
ease. An excited state of the blood-vessels, in this condition 
of the capillaries, is much more liable to terminate in disease, 
than when the entire assemblage of the functions of the skin is 
in a normal state. 

In some degree allied to this last mentioned condition of the 
capillaries, is the congenital or acquired debility of the cutane- 
ous vessels. Such a state produces these affections characte- 
rized by a deficiency of vigour in the capillary vessels of the 
skin, producing alopecea, elephantiasis, ptyriasis, ichthyosis, etc. 

The exciting causes of all cutaneous diseases may be referred 
to such as act directly on the skin ; to the sympathy which the 
skin experiences with the derangements, either functional or 
organic, with other organs, and to the peculiar effects of a spe- 



EXCERNENT SYSTEM. 341 

cific contagion on the dermoid surface, which this part expe- 
riences in common with other tissues. 

Among the externa] irritants of most frequent occurrence is 
caloric. The atmosphere acts directly on the external surface 
of the body, and when a high atmospheric temperature exists, 
an active and an extremely irritative action characterizes the 
diseases of the skin. The increased action of the vessels on 
the surface, from an increase of atmospheric heat, is familiar 
to every one, and scarcely needs an illustration. Eruptions are 
much more severe in hot climates than in temperate regions, 
and, as would be supposed would be the case, are in general 
more frequent. In tropical climates the lichen tropicus, or 
prickly heat, is much more severe than in the tropical summers 
of some temperate climate. The eruptions common to young 
infants, from the highly vascular condition of the skin, are 
greatly increased, if not altogether produced, by the direct ap- 
plication of heat to the surface. Strophulus is much more ex- 
tensive in summer than in winter, or where, from the over 
tenderness of parents and nurses, the skin is maintained in a 
state of excessive heat from artificial warmth of the apartment, 
or from a too great quantity of clothing, especially if it be of 
an irritative nature. Roseola, also, is a cutaneous affection, de- 
pending on the direct action of heat for its production. It occurs 
more frequently in summer and autumn than at any other season 
of the year; and although occasionally complicated, as indeed 
are all other diseases, with a disturbance of the digestive organs, 
yet it depends for its existence on the immediate action of heat. 

Most cutaneous diseases are very seriously aggravated on 
the approach of summer, although there are some, such as 
lepra and inpetigo, which exhibit an opposite effect, being re- 
lieved in summer, and becoming more aggravated in winter. 

Exposure to the rays of the sun, to the heat of a strong fire, 
and, on the same principle, to extreme cold, will cause cutaneous 
inflammation ; for a direct injury is thus produced on the skin, 
terminating in various kinds of inflammatory affections. The 
same effects follow the application of a blister, the bites and 
stings of insects, punctures, and any corrosive or irritating 
substances. 

Uncleanly habits are the great sources of cutaneous diseases, 
as is evident from the effects of ablution in most of these diseases 
among the poor. Where this is neglected, and a derangement 
in the secretory functions of the skin is allowed to take place, 
irritation and itching are the consequences ; and the scratching 
used for its relief aggravates the existing irritation, until ulcers, 
and a complication of cutaneous affections, which often defy all 
attempts at classification, are the result. In connection with 



342 DISEASES OF CHILDREN. 

this part of the etiology of cutaneous disease, is the burrowing 
of the small insect, acarus scabiei, giving rise to the well known 
cutaneous affection, which derives its name from the incessant 
itching — the itch. 

Another class of causes is to be found in the disordered action 
of the internal mucous surface, and principally of that of the 
alimentary canal. This is a frequent cause of cutaneous dis- 
ease, and numerous facts go to show the physiological and pa- 
thological connection between these parts. The healthy action 
of the one is very clearly connected with that of the other, and 
more especially with the mucous lining of the gastro-intestinal 
surface. This part is so evidently connected with the patho- 
logical condition of the skin, as rarely to be affected without 
some change being produced in the action of the cutaneous 
system. Scarcely can any derangement arise in the circulation 
and secretion of the mucous membrane of this part, without 
the cutaneous surface participating in some degree in the 
change, and suffering likewise in its circulation and secretion. 

Cutaneous affections may arise from a simple derangement 
of the functions of the part. A temporary indigestion will cause 
uticaria, a variety of purpura combined with the peculiar 
irritative action of urticaria, and other affections of a similar 
character. 

Many acute cutaneous diseases have their origin in inflam- 
mation of the same membrane; and those arising from the 
attack of an eruptive fever have been referred to this as a 
cause. But this is not the cause of the cutaneous eruption ; it is 
a part of the disease which simultaneously affects both the skin 
and mucous membrane ; and in some of these affections the 
cellular tissue and meninges of the brain, or peritoneal coat, 
also participate in the disease. 

Another class of diseases, differing from all others principally 
in the periodical changes they undergo, in their incipiency, 
maturation and decline, arise from a specific contagion. Besides 
this, they are also characterized by the presence of febrile 
action, from which circumstance they have been denominated 
eruptive fevers. The presence of inflammation in the skin, 
although characteristic of these affections, does not always 
necessarily exist; in some severe forms it has been absent 
altogether, and the disease has spent its force, generally having 
a fatal termination, on the brain or other internal organ. The 
disease of the skin is therefore but one of the strongly marked 
symptoms of this class of diseases, but so generally uniform in 
its appearance, that its absence is regarded as an irregular 
course : its presence is, in every instance, essential to their proper 
developement. 



EXCERNENT SYSTEM. 343 

Among the contagious cutanei are the syphilida, differing from 
the others in the absence of the changes occurring in the eruption 
at regular periods, and the formation of the disease, without 
the necessary fever existing in the former. 

General Pathology. — The congenital marks or spots, known 
by the name of ncevi materni, whatever be their form or 
colour, are in some respects allied to malformations. Some, in- 
deed, may be regarded as such, while others possess an active 
circulation, making them closely allied to inflammation. Some 
of these spots appear to be simply a change in the natural pig- 
ment ; others, are the excessive developement of the papillae 
and vascular net-work of the skin, with more or less vascular 
action. Although seated generally in the parts just mentioned, 
other textures of the tegumentary system may become like- 
wise affected with this congenital hypertrophy. 

The most common affections of the skin are inflammatory 
in their nature, varying in their appearance according to their 
seat in the different textures, and according to the violence of 
the affection ; these different forms may also arise from some 
peculiar action of the exciting cause, producing in the same 
texture a circumscribed, instead of a diffuse inflammation. 

Inflammation of the simplest kind is found in the external or 
cuticular surface of the skin. When this part is affected with 
a diffuse inflammation, it constitutes erythema, erysipelas, etc. 
In these affections there is but little swelling ; when these super- 
ficial inflammations are diffused, and are accompanied with 
elevated patches, they are denominated wheals, and constitute 
the disease termed nettle rash. The general termination of 
these rashes is by resolution, but not without the secretory- 
function of the cutis being materially impaired ; a separation 
of the cuticle is the consequence of this derangement of the 
secretory action. Dr. Cragie explains this process by referring 
to the apparent fact, that the cuticle is secreted in successive 
layers, first fluid, then becoming hard. From the derange- 
ment of the secretory functions of the part, this process is im- 
perfectly performed, and the connection between the secreting 
surface and the recently secreted portion becomes dissolved ; 
therefore, during the progress of the disease no new cuticle is 
formed. The morbid action gradually subsides, and as the 
cutis recovers its healthy tone, a new and delicate cuticle is 
formed.* 

Sometimes, however, a long continued inflammatory action 
of this outer surface of the cutis results in the effusion of a 

* Elements of the Practice of Physic, etc., by David Cragie, M. D., F. R. S., 
etc. ; Edinburgh, 1836. 



344 DISEASES OP CHILDREN. 

watery fluid beneath tlie cuticle, forming blisters or blebs ; this 
is the most severe form of inflammation of this part. 

The cause of this species of inflammation also modifies its 
appearance. The inflammation of the skin in measles and 
scarlet fever is always peculiar, both in colour and form, 
although the cutaneous part of the disease does not extend any 
deeper than the outer surface of the chorion. 

Papillary diseases, as strophulus lichen and prurigo, are 
seated in the small eminences of the cutis, called papillae. 
These affections are slight, and usually terminate in resolution. 

The inflammation affecting the substance of the skin, when 
occurring in a circumscribed form, gives rise to pustules. This 
kind of inflammation may either arise on the outer surface of 
the skin, and successively proceeding inwards, and affecting the 
other portions, or may commence originally in the substance of 
the skin itself. This circumscribed form produces pustulous 
inflammations. From the progress of the vesicle inwards, it 
is evident that a distinction between the vesicle and pustule is 
very difficult to make, as the disease, at first affecting the outer 
surface of the skin alone, and exhibiting only the characters 
belonging to a vesicular eruption, may, from subsequently in- 
volving other portions, become a real pustular disease. Such is 
the psydracium ; a small, circumscribed elevation of the cu- 
ticle first appears : the parts beneath are then involved, and 
several of them uniting, discharge a small quantity of puriform 
matter ; the affection is so superficial as never to leave a scar 
or depression. This disease is the closest allied to the vesi- 
cular of all the pustular forms. The next disease, and more 
approximating to the real pustule, is the achor ; this, like the for- 
mer, although discharging purulent matter, leaves no scar. The 
favus exhibits a deeper affection of the cutis, the pustules be- 
ing surrounded with a marginal ring, indicating a higher grade 
of inflammation and a more extended disease. On the disap- 
pearance of this pustule a scab forms, which, on becoming de- 
tached, leaves a slight scar. The phlyctidium is the pustule 
produced by the small-pox, or by the application of tartar 
emetic ointment. It is characterized by a circular inflamma- 
tion of the skin, surrounded by an inflamed circle, which is the 
outer part of the skin much injected and elevated. Suppura- 
tion occurs within the inflamed border, and never extends be- 
yond it. The most perfect form of a pustule is the phlyza- 
cium. It commences in the substance of the integuments, and is 
a large pustule on a hard circular base, of a red colour, slow in 
its progress, and its suppuration always attended with a consi- 
derable loss of substance, and a deep scar. These pustules form 
the disease known by the general name of ecthyma; one form 



EXCEENENT SYSTEM. 345 

of which, from its occurring in infants, has been made a distinct 
species. Inflammation attacking the sebaceous follicles, the 
corial follicles or sudatory pores, the sacs at the root of the hairs, 
all produce pustulous diseases, having the phlyzacium for their 
character. 

It is very rare that the internal surface of the skin becomes 
originally the seat of the disease, without involving likewise the 
adjacent cellular tissue. When this occurs, the highly inflamed 
tumour, known as the furunculus, or boil, is the result. The 
hordeolum, or sty, is also one of the forms of this inflamma- 
tion. It appears to be an inflammation of the conical prolonga- 
tions of the sub-cutaneous cellular tissue, which penetrates the 
chorion in every part ; therefore, the affection can rarely occur 
without extending to the parts beyond the skin. Its progress 
is always to the surface, with severe inflammation, imperfect 
suppuration, and sloughing in the internal parts. This slough, 
or cone, is formed of the cellular membrane, infiltrated with pus. 

Although these are the more marked and prominent charac- 
ters of cutaneous inflammation, yet when more than one part 
is simultaneously affected, it is evident that it may be difficult 
accurately to distinguish them for classification. This diffi- 
culty more commonly occurs in chronic inflammations of the 
skin, where the entire mass of the various parts of the chorion 
may become more or less involved in the morbid action. The 
consideration, therefore, of their causes — whether of local or 
general origin ; whether from constitutional derangement ; from 
disordered functional or organic action of the gastro-intestinal 
mucous membrane, or from the action of a peculiar infection on 
the system — becomes practically of more importance than the 
simple appearance of the disease. The classification of cuta- 
neous affections, as papular, pustular, vesicular, etc., however 
correct it may be, can yet go but little to direct us in their 
treatment. As they are for the most part symptoms of some 
other disordered action, the disease itself, of which they are 
but the symptoms, should, if possible, in the first place be as- 
certained ; while the actual character of the cutaneous affec- 
tion shows the violence of the constitutional derangement, or 
marks the degree of predisposition in the affected part, to be- 
come inflamed on the developement of the exciting cause. 
When no such constitutional disorder exists, and it is ascer- 
tained that the disease is purely local, the treatment is neces- 
sarily simplified to local applications alone. 

The following arrangement is proposed, with reference to 
those diseases of the skin which are found to affect children ; 
all others are omitted. It is a modification of that proposed 
by Dendy, and is merely intended to simplify the matter, 

44 



346 DISEASES OP CHILDREN. 

and to place it in the condensed form necessary in a treatise 
devoted to general subjects. For more extended information, 
the various and extended treatises on cutaneous diseases must 
be consulted. 

MORBID CONDITIONS OF THE SKIN, INDEPENDENT OF CONSTITU- 
TIONAL CAUSES. 
I. 

From Local Peculiarities, or f Ncevi materni, Verrucse Cri- 
Conformations of the Skin. ( nones Alopcecea. 

ii. 

From External Irritation. j El ff f'. Pernio ' V ^<*tion, 

( Intertrigo. 

MORBID CONDITIONS OF THE SKIN FROM CONSTITUTIONAL CAUSES. 

I. 

From Gastric or Intestinal Dis- ( Strophulus, Prurigo, Impetigo, 
turbance^ during Lactation or < Crusta lactea, Erysipelas, 
Dentition. ( Jaundice. 

ii. 

C Urticaria, Lichen, Roseola, 

From Gastro-Enteric Irritation J Herpes, Purpura, Furuncu- 

at all periods. ^ lus, Eczema, Psoriasis, Por- 

( rigo favosa, Tinea. 

in. 
From Constitutional Debility, Ecthyma, Rupia, Pemphigus. 

IV. 

C Scarlatina, Rubeola, Vario- 
From Specific Contagion. < la, Varicella, Vaccinia, Sy- 

( philida, Scabies. 

FROM LOCAL PECULIARITIES, OR CONFORMATIONS OF THE SKIN. 
NCEVI MATERNI. 

There are two varieties of ncevi ; flat blotches or apparent 
stains, and elevated tumours, characterized by a preternatural 
developement of some part of the vascular net- work on the 
sub-cutaneous cellular tissue. 

The first kind are the stains known as port wine marks, or stains 
resembling those produced by a raspberry. They have also 
been seen of a yellow, brown, blue and black colour. They 
are the effect of a diseased action in the corpus mucosum, 
where the capillary vessels deposit the pigment, or they may 
exist in the vessels themselves ; and a distinction, not however 



EXCERNENT SYSTEM. 347 

of much practical utility, has been made between pigmentary 
and vascular noevi. 

This alteration in the normal action of the skin, from the in- 
timate relation subsisting between all the parts, extends some- 
times to every portion of the tegumentary layers and their 
respective functions ; it has therefore happened that these 
spots have, from the altered action of the papillae of the skin, 
been the seat of hairs of different colours. These coloured 
spots always become paler on pressure, and are increased in 
intenseness under the influence of atmospheric heat, or any 
thing that will increase the vascular circulation. 

The congenital elevated tumours are of two kinds : erectile 
tumours and varicose tumours. The former are of various 
colours and shapes, and from this circumstance have been 
compared to cherries, raspberries, strawberries, etc. Some- 
times they have a broad, and at other times a pediculated 
base. They are found usually on the lips, eyelids, cheeks, 
inside of the thighs, arms, etc. At first they are often very 
small in size, but their increase is uniform but slow. 

Congenital tumours are sometimes more deeply seated, and 
of a less regular shape ; and from the mass of sanguineous 
vessels of which they are evidently formed, are more properly 
varicose tumours, than tumours from a preternatural develope- 
ment of the capillaries, or the abnormal process of nourishment. 
These have been known also by the names of varicose wens, 
sanguineous fungi, etc. These affections are in general not to 
be regarded as serious, unless they are of a large size, or grow 
rapidly; when such is the case, they may form ulcerations, 
ending in a fatal hemorrhage. 

Treatment. — The various methods of treating noevi are 
compression, refrigerant applications, styptico, cauterization, 
artificial inflammation, ligatures to the tumour, or the blood- 
vessels supplying it, or excision with the knife. 

Compression is only applicable to small tumours situated 
over hard parts. Mr. Abernethy advises, in addition to com- 
pression, the simultaneous use of cold and styptic applications. 
Where styptic remedies are used, a strong solution of alum is 
probably about the best ; although these remedies will be found 
of little avail. 

The method of exciting inflammation in them by introducing 
the vaccine virus, has been advised. The application of tartar 
emetic ointment for the same object, has also been successfully 
used by Dr. Young.* 

Cauterizing has been long in use for treating ncevi. It is only 

* Glasgow Med. Journ., vol. i. p. 93. 



348 DISEASES OF CHILDREN. 

necessary in small tumours to touch the superficial parts in 
succession, and they will in general shrivel up and disappear. 
For this purpose, quick lime, nitrate of silver, and caustic potash 
have been used ; the last mentioned article more easily assimi- 
lates with animal substances, and is therefore to be preferred 
to the others. Caustic applications have been freely used by 
Mr. Wardrop,* in large and bloody ncevi, without any hemorr- 
hages following; and their use has been uniformly successful. 
Having excised small tumours with a knife, I can unhesitatingly 
give the preference to caustic applications. On the same prin- 
ciple nitric acid is also useful, and 1 have completely destroyed 
small ncevi by its application. 

Where these tumours are pediculated, the ligature has been 
used; it was first recommended by M. A. Petit, f Messrs. Bell 
and White have recommended, where the base of the tumour is 
large, to pass a needle through it armed with a double ligature, 
and by tying it on both sides of the tumour, thus enclose it on all 
parts. Ligatures have also been applied to the principal artery 
going to the tumour ; these are used when the ncevus is of so 
great a size as to forbid its removal by any other means, or 
when it involves important or inaccessible parts. It is also used 
as a preparatory step when the tumour is to be excised, for the 
purpose of preventing excessive hemorrhage. 

Among other methods of treating ncevi, it has been proposed 
to pass a seton through them ; J this, of course, is applicable to 
erectile, and not vascular tumours. Dr. Hall has recommended 
the introduction of the cataract needle into the tumours, and, 
without withdrawing the instrument, to pass it in several di- 
rections in the body of the tumour.|| 

It is very important for the welfare of the child, that the re- 
moval of these tumours be not attempted while the child is 
quite young. When, however, they are evidently on the in- 
crease, the operation should not be delayed, for their great 
size may render this not only difficult, but dangerous. 

VERRUCiE.-WARTS. 

Warts are small elevations, of a hard and rough character, 
produced by hypertrophy of the papillae, or of the differ- 
ent layers of the skin. They are insensible on their surface, 
but at times have some inflammation and increased nervous 
sensibility surrounding them. Although occurring at all ages, 
yet childhood is the time of life at which they are most com- 



* London Lancet, 1827. 

t Obs. Chirurg., Paris, 1700. 

$ Lawrence, in the London Lancet, 1831. 

II Marshall Hall. Lond. Med. Gazette, 18. 



EXCERNENT SYSTEM. 349 

raon. After a few years they disappear spontaneously, with- 
out returning. In youth, however, they not unfrequently are 
reproduced after having disappeared. They appear singly 
and in clusters on different parts of the body, but more espe- 
cially on the hands. 

Treatment. — They may be removed by excising them in 
thin successive layers ; and when the blood begins to flow, the 
surface should be cauterized with nitrate of silver. They may 
also be removed by tying a fine silk or horse-hair around them, 
if the narrowness of the base will admit of a ligature. 

Any escharotic substance will remove them. The acrid 
juices of several vegetables are used for this purpose, such as 
the chilidonium majus, juniperus sabina, ficus indica, etc. — 
Among the mineral escharotics are the muriate of ammonia, 
which may be rubbed on the warts ; first dissolving a portion 
of it by moistening it, and the nitric acid carefully applied 
only to the excrescence. The last application is decidedly 
preferable to any other means that has been recommended ; 
they will almost certainly be removed after a few applications. 

CRINONES. 

These are the minute black spots which, on being pressed 
out, assume the appearance of worms. They appear on the 
face of youth, and on the back and limbs of infants, and are the 
inspissated sebaceous fluid in the cutaneous follicles. From the 
resemblance they have to worms, they have been regarded as 
living parasitical animals. Such is the opinion of Ambrose Pare 
and Dr. Good ; and the latter describes them under the name of 
moris gardii. Others have regarded them as the morbid pro- 
duction of hairs, whence it has received the name of morbus 
pilaris. 

Dr. Good quotes M. Bassignet, as desribing the existence of a 
peculiar affection of this nature, among new-born children in 
the town of Seyne, in 1776.* It appeared in the form of bristle, 
producing a violent itching, hoarseness, inability to sleep or 
suck. The treatment pursued was friction over the body 
with the hand, which produced dark, rough filaments, resem- 
bling a hair. For this and other similar affections he advises 
a solution of coculus indicus, and the powder of the cividilla, a 
species of veratrum, sprinkled over the bed-clothes. The 
extreme pungency of this article requires great caution to be 
used in applying it as a remedy to young children. 

These affections appear to have been confounded with the 

* Hist, de la Soc. Roy ale, 1776. 



350 DISEASES Or CHILDREN. 

simple collection of inspissated sebaceous matter in the cuta- 
neous follicles, which will at times become a source of great 
irritation and inflammation. The malis a crinonibus, morbus 
pilaris, and malis gordii, have all been regarded as one and 
the same disease. 

ALOPECIA. 

Baldness is common to all ages ; in children it occurs in 
spots and serpentine lines. The congenital absence, and the 
ulterior absence of the hair, is of very rare occurrence. In- 
stances, however, of this have occurred, and a case is given by 
Rayer.* 

The variety of baldness occurring in children has been 
described under the name of porrigo declavans. It occurs in 
patches, sometimes circular, and at other times in a waving 
and serpentine form, which are entirely divested of hair, with- 
out the surrounding part having less than the normal quantity. 
These patches and lines extend, and several of them uniting, 
baldness to a very great extent ensues. It is difficult, if not 
impossible, to assign any cause for this defect, no eruption nor 
inflammation either preceding or attending the affection. 

Treatment. — The applications most in common use are those 
of a stimulating nature. Decoctions of walnut leaves, of the 
solanum niger, centaurea minor, stimulating ointments, made 
of the essential oils, have all been used. Mercurial ointment 
has also been used with advantage. It is often a very obstinate 
disease, and will frequently resist the application of remedies 
for months, and even for years. 

FROM EXTERNAL IRRITATION. 
ENCAUSIS.— BURN. 

As accidents from burns and scalds are very common among 
children, it will be useful to devote a short space to the con- 
sideration of the morbid changes thus produced, and their most 
approved treatment. 

A great diversity of opinion has for a long time prevailed on 
the subject of their treatment, and remedies of the most opposite 
nature have been recommended for their most speedy cure; 
and, although a wide difference of opinion still exists on this 
subject, yet more rational views now exist, since a greater ac- 
curacy has been made in the division of injuries from these 
causes, and their classification, according to the extent of the 
injury. 

* Op. Cit., p. 1050. 



EXCEItflENT SYSTEM. 351 

Burns and scalds are serious in proportion to their extent 
and depth ; the danger being greater where these two circum- 
stances are united. The most common occurrence whereby 
children are burned, is by their clothes catching fire. Scalding, 
also, is another frequent accident, but not so extensive nor so 
serious as the former. For the proper management of these 
accidents, according to their pathological condition, it has been 
usual to divide them according to their depth, or the number 
of tissues affected. That of M. Dupuytren is the most com- 
prehensive, embracing, as it does, every form in which the 
effect of caloric occurs, from the simple erythematic inflam- 
mation, to the entire combustion of the part or member. 

There are, according to him, six degrees of burns. The first 
is that of a simple redness ; the second, vesication ; the third 
producing a sloughing of the rete mucosum ; the fourth, slough- 
ing of the derma ; the fifth, sloughing of the muscles ; and the 
sixth, the complete destruction of the limb. 

Erythema is the slightest effect produced by caloric, and it 
may occur from any cause by which heat is applied to the sur- 
face of the body. When water, at 150° Fahrenheit, is applied 
to the skin, rubefaction is all the effect produced. 

Where the cause is more powerful, blistering is produced, 
accompanied with much more pain, especially when the nerves 
of the cutaneous surface are exposed to the action of the air, 
from the rupture of the raised cuticle. This degree is at times 
attended with irritation of the gastro-intestinal mucous mem- 
brane. 

From the application of a still more energetic cause, the third 
degree, or sloughing of the rete mucosum, is produced. This, 
besides the prolongation of the cure, from the necessity of sup- 
puration, and the complication of gastro-enteritis, when the 
burn is of any extent, makes this state one of great danger. 
The well known sympathy of the internal mucous membranes 
with the cutaneous surface, is the cause of this complication, 
which, however, does not uniformly take place in burns of the 
first and second degrees, from the rapidity of the cure not 
allowing time for the developement of gastro-enteritis. The 
two first usually heal without leaving a scar ; this never does, 
as it is never cured by resolution. 

In burns of the fourth degree, the sloughs must separate be- 
fore the part can heal and cicatrize, while a high degree of in- 
flammation invariably attends the injury, and from this cause, 
and its long continuance, greatly endangers life ; the danger be- 
ing proportionate to the extent and depth. In burns of the third 
degree, the inflammation appears in a few hours, at most, after 
the accident, reaction following shortly after a comparatively 
slow action of heat. The rapid disorganization occurring 



352 DISEASES OF CHILDREN. 

from the sudden application of a high degree of heat, prevents 
reaction for some days in those burns classed in the fourth 
degree. The burnt part is dry and shrivelled, and completely 
deprived of vitality. The application of the actual cautery, or 
the moxa, produces burns of the fourth degree. 

Those of the fifth and sixth are uniformly fatal ; the exten- 
sive slough and suppuration causing death in such as escape 
the first shock. 

Treatment. — The indications, in burns of the first and se- 
cond degrees, are to relieve the pain and arrest the inflamma- 
tion ; in those of the third and fourth, to prevent constitutional 
symptoms and excessive suppuration, and to promote a speedy 
separation of the sloughs. In the other two, but little else 
can be done besides removing the limb, if the injury has occur- 
red so as to admit of amputation. 

The means of fulfilling the indications mentioned first, have 
been exceedingly variable, and entirely opposite in their nature. 
These measures have been, refrigerants, heat, stimulants, astrin- 
gents and oily substances. Each have had powerful advocates, 
and the success which, it is alleged, has followed their use, is 
attributable to the different stages of the burn, and the influ- 
ence of the constitutional vigour in controlling their effects. 

In the simplest form of the burn, producing an erysipelatous 
inflammation, the refrigerant plan is unquestionably the best; 
and it is difficult to conceive how the opposite course can be 
in any way beneficial, unless the patient, from the shock, suffers 
from a feeling of coldness. Instinct prompts us to use at once 
such measures as will relieve the violent pain in the part, which 
is speedily affected by cold or iced water; and slight burns or 
scalds are in a short time cured by these means. 

Cloths, wetted with cold water, or bladders partially filled 
with pounded ice, should be applied to the parts ; the latter, 
however, with great caution, especially if the burn be extensive. 
Although ice has been used with great advantage, yet it is by 
far the safest practice to use compresses dipped in cold water. 
Where cold is quickly used, vesication may often be pre- 
vented ; for a burn of the second degree will occur, from a 
continuance of the high action constituting the first degree ; and 
that which at first was an inflammation simply of the affected 
part, may pass into that where there is a separation of the cu- 
ticle, and the effusion of serum beneath it. Evaporating washes, 
which act on the same principle, are useful ; and a small quan- 
tity of brandy or alcohol may be added to the water, and the 
part covered with a thin cloth, to promote evaporation. 

Heat has been a popular mode of treating burns, and applied 
by exposing the part to the action of the fire. This method is 
only applicable to burns of very limited extent ; and from the 



EXCERNENT SYSTEM. 358 

severe pain attending it, cannot be applicable under any other 
circumstances. The modus operandi is, by continuing the vio- 
lent action of the part already affected ; the vitality is at length 
destroyed ; the pain ceases ; the part becomes hard, resembling 
horn, and separates from the living part. It is evident that 
this cannot be applied, with any prospect of relief, to any other 
than burns of the first degree. 

In almost every kind of burn, except such as have been 
designated as the fourth, fifth and sixth degrees, astringents have 
been used with success ; and solutions of alum, or of the acetate 
of lead, and Goulard's cerate, have been employed, and cold 
infusions of the astringent vegetables. Sometimes, when the 
pain is great and the inflammation severe, the application of 
some narcotic will be highly useful ; such as an infusion of bel- 
ladonna, or of poppy heads. A poultice, made with boiled 
potatoes, milk and water, is a very soothing application in recent 
burns ; and raw potato, scraped, is also in common use, and 
where there is no vesication, is a very useful remedy, possess- 
ing in this state some slight narcotic power. 

It has been usual to treat burns of the second and third 
degrees on the stimulating plan, with warm spirits of turpentine 
or alcohol, applied at first, or the less stimulating application of 
basilicon ointment. This is the course recommended by Dr. 
Physic, and generally pursued in this country ; but the internal 
stimulating plan, as recommended by some, can hardly be de- 
fended on sound physiological principles, unless, under peculiar 
circumstances, when, from the extreme shock, the nervous en- 
ergy is impaired, and the circulation much lessened in its force, 
producing shivering and a general coldness of the surface. 
When great pain or prostration attends accidents of this kind, 
an opiate is indispensable. 

The skin of the raised cuticle should be preserved as much as 
possible ; it ought simply to be punctured to let out the serum, 
without detaching any portion. Warm and stimulating appli- 
cations should then be used as above mentioned, gradually les- 
sening the strength, until the peculiar irritation resulting from 
the burn has disappeared. After this the inflammation must 
be treated on ordinary principles, with leeches to the surround- 
ing parts, poultices, etc., according to the indications in each 
case. When the cuticle is granulating, the annexed prescription 
is recommended, by Sir A. Cooper, as exceedingly efficacious in 
promoting the formation of the new cuticle ;* it should be applied 
by means of lint wetted with it, with oiled silk over the dress- 

* Ifc Zinci. Sulph., gr. ij. 

Liq. Plumbi. Acetat. Dilut., gj. M- 
45 



354 DISEASES OF CHILDREN. 

ing, to prevent evaporation. Perhaps as good a principle for 
treating burns which have produced an elevation and loss of 
the cuticle, is to supply the deficiency, and thus exclude the air 
from the part. This is to be effected by the application of the 
ordinary liniment of lime-water and linseed oil, with which a 
layer of carded cotton may be saturated ; or with cotton 
smeared with some mild and unirritating fatty substance. 

The chloride of lime has of late been used as an application 
to burns of the second and third degrees; the pain it is said is 
immediately diminished, the suppuration lessened, and the 
sloughs speedily separate, leaving a healthy condition of parts 
beneath. The subjoined is the formula recommended in the 
Bulletin General de Therapeutique, July, 1838.* Lisfranc, also, 
in the Gazette Medicale, for March, 1835, bears his testimony to 
the valuable properties of chloride of lime in burns. He applies 
over the injured parts compresses, spread with ordinary cerate, 
with holes in them, that the burnt parts may be exposed ; the 
whole is then covered with lint, saturated with a solution of 
chloride of lime. This, as well as the chloride of soda, may 
also be used with great benefit in the first degree, as well as in 
the second and third. 

Creosote has also recently been used with success in burns 
of the second and third degrees, applied by means of rags 
wetted with a mixture, consisting of twelve drops of creosote 
in two ounces of water. The burns quickly become desiccated, 
and heal with a scab or crust, f 

With regard to the subsequent treatment of these accidents, 
and those of the fourth, fifth and sixth degrees, it must be directed 
on general principles ; and works more particularly devoted to 
surgery must be consulted for further details. 

PERNIO.-CHILBLAIN. 

This affection is known by redness, itching and heat on the 
feet, nose, ears, &c, from cold, or from the sudden exposure 
to a warm fire, after being subjected to the influence of a very 
low temperature. When the effects are more severe, or have 
lasted for a short time, the parts will swell and become livid, 
which is the second degree of chilblain. When the deranged 
action proceeds still further, blisters are formed, which sometimes 
degenerate into ulcers, attended with sloughing. 

* R CalcisChlorid., gss. 
Aqua Pont. ftj. 
Mucilag. Gum Arab., f ij. 
The chloride to be mixed gradually by rubbing with the water, and when clear, 
mix the mucilage. 

1 New Remedies, etc, by Robley Dunglison, M. D.; Philad. 1839, p. 166. 



IXCERNENT SYSTEM. 355 

Treatment. — The treatment naturally divides itself into 
preventive and remedial ; the former being of great importance 
in children, who are incapable of attending to the proper 
quantity and arrangement of their cloths. 

Although warm clothing is necessary in winter, yet it is a 
well known fact, that a great susceptibility to the impressions 
of cold is generated by keeping parts too warmly covered. 
When children are observed to have a strong tendency to 
chilblains, the feet, which are the parts most often affected, 
should be frequently rubbed. While a sudden exposure to 
great changes of temperature ought to be avoided, the child 
should be gradually inured to the ordinary vicissitudes of 
the cljmate, as one of the best preventives of this and other 
effects of~a- low temperature. 

When a part appears to be frozen, the best application is 
snow, or water at the temperature of 32°, or at a higher tem- 
perature, poured in a stream on it ; the itching and heat will 
thereby soon be removed. A mixture of alcohol and water 
in equal parts, or of vinegar and water in the same proportions, 
is also very useful in the first stages of chilblains. Stimulating 
applications appear to be the most useful in the subsequent 
stages of chilblains, such as spirits of turpentine, or basilicon 
ointment mixed with spirits of turpentine. Soap liniment, either 
alone or combined in equal proportions with spirits of turpen- 
tine ; the latter, also, with the oil of rosemary, has been greatly 
extolled in the treatment of these affections, or the annexed 
formula.* When vesication has taken place, the different 
preparations of lead are generally used, as the poultice of lead 
water,f or Goulard's cerate. 

Chloride of lime has recently been used in the treatment of 
chilblains in every stage of the affection, both where the skin 
continues unbroken, and where ulcerations have formed. It 
has been employed both in the form of liniment and solution, 
and much used by the German physicians-! 

Creosote has also recently been introduced into practice, 
and Dr. Herndon|| considers the creosote ointment as the best 
remedy yet known for the treatment of chilblains. § Excessive 



* # Tinct. Cantharid., 3iij. 

Linim. Sap. C, §ij. M. 
t fy Aq. Litharg. Acet., 3j 



fy Calcis. Chlorid., 
Boracis, aa. 3j. 
Oxung., I}. M. 



M^« pSlk.fi s. M. " Amer - Med ' IntelL ' March < 1838 - 

t $ Calcis. Chlorid., 3iij. I § ^ Creosot tt xxx 

A SolV n in ., , I 01. Amy|. Dulc, 

Aqu.DesUl. jft j. Cerati.^.gj. 

Vini Opii, 3j. M. 



356 DISEASES OP CHILDREN. 

inflammation, or suppuration and sloughing of parts, must be 
treated according to the principles established in surgical 
treatises. 

VESICATION. 

Blisters sometimes become exceedingly troublesome, and 
even dangerous in young children, from excessive inflammation, 
which occasionally terminates in protracted sloughing. These 
effects are to be prevented by carefully watching the progress 
of the blister, which should only be left on from two to four 
hours, and on the appearance of a considerable degree of red- 
ness, by removing the plaster, and applying a little unguentum 
resinosum. 

When excessive inflammation occurs in a blister, a soft poul- 
tice of bread and milk, or slippery elm, should be placed over 
it. The soothing course is decidedly the best when the con- 
stitutional symptoms are severe ; and when the blistered sur- 
face assumes an irritable and ulcerated appearance, a sedative 
ointment, composed of lime water, oil of almonds and simple 
cerate, will be the most suitable application. 

After the ulcerated surface becomes pale and ash-coloured, 
it will be necessary, under these circumstances, to use some 
stimulating application, as the unguentum resinosum, or a solu- 
tion of the nitrate of silver, ten grains to the ounce, applied by 
means of a camel's hair pencil. When more stimulation is 
required in cases of the formation of sloughs, lotions of chloride 
of soda, or the yeast poultice, will become necessary. The 
best application, in severe cases of sloughing blisters, is the 
acetate of copper, used either in solution, or in the form of 
ointment. 

INTERTRIGO. 

This is an erythematous affection, without any febrile affec- 
tion, and known by the existence of blotches of various sizes, 
of a red colour, in different parts of the body, In young in- 
fants who are fat, the folds of the skin, by causing the rubbing 
together of the parts that are in contact, are constantly exposed 
to this form of cutaneous disease. It will, therefore, be found 
in the axillae, groins, upper part of the thighs, and wherever the 
skin lies in folds, or is wrinkled. 

A common cause of this disease in infants, is the continual 
wetting of the clothes with the urine and feces. The upper 
parts of the thighs and scrotum thus become the seat of a 
troublesome, and often an obstinate inflammation, of a bright 
red colour, without much change in the affected part, but at- 



EXCERNENT SYSTEM. 357 

tended with considerable elevation in the temperature, and 
great itching. There is also a morbid secretion of sero-puru- 
lent fluid. 

A strict attention to cleanliness, by frequently washing the part 
with castile soap and warm water, and often changing the wet 
clothes, is generally all that is required in the treatment. 
Where there is much discharge from the part, it may be dusted 
over with the ordinary flesh powder, or with equal quantities 
of this mixed with finely powdered oxyde of zinc, or lapis cali- 
minaris of the shops, when the inflammation appears to be 
severe. 

In severe cases rhagades or fissures appear, which are at 
times very obstinate and painful. Besides the rational means of 
strict cleanliness, mild ointment should be applied to the part, 
or a mixture of the white of an egg and olive oil, to supply 
the deficiency of natural mucus of the part, where the fissures 
are dry and hard. The powder of lycopodium has also been 
advised for this condition of the skin. 



FROM GASTRIC DERANGEMENT DURING LACTATION AND DENTITION. 
STROPHULUS. 

This is very common in young infants, and has been de- 
scribed as existing under different varieties, according to the ap- 
pearance and form of the eruption. It is characterized by a 
white or red papulous appearance of the skin, appearing and 
disappearing successively. 

Etiology. — This is one of the earliest diseases of infancy, 
and is evidently connected with an irritable condition of the 
skin, produced either by the warmth or friction of the clothes, 
or the temperature of the season or apartment. It is, how- 
ever, evidently connected with gastro-intestinal irritation, 
arising either from improper food, or the acid condition of the 
contents of the stomach from indigestion. 

Semeiology. — The eruption of strophulus has different ap- 
pearances, from the colour, size and arrangement ; and it has 
accordingly been arranged by Willan agreeably to its different 
appearances. 

Strophulus intertinctus is where the papula? are of a vivid 
red and prominent, with an erythematous inflammation inter- 
mingled with them. The eruption is chiefly situated on the 
face, arms, and back of the hands, and will often continue for two 
or three weeks without any evident constitutional disorder. 
It sometimes entirely vanishes, to reappear in a few hours. 



358 diseases or children. 

When it permanently disappears, it leaves a furfuraceous des- 
quamation. 

Strophulus albidus of Willan, is where the papulse are small 
and white, with a slight circumscribed redness. 

Strophulus candidus is where the papulse are also white, but 
larger, and destitute of the circumscribed redness above men- 
tioned. They are also smoother, and with somewhat of a lustre. 

Strophulus confertus is characterized by a very thick eruption 
on the face, trunk and extremities. They are nearly confluent 
on the face ; their colour is not so bright as in strophulus inter- 
tinctus. The eruption on the trunk is mostly confined to the 
loins, and is more scattered than that on the face. In both 
upper and lower extremities the eruption usually forms in clus- 
ters, and is attended with great itching ; it may recur for a 
long time on the thighs and loins. 

Strophulus volaticus is a disease of a much later period than 
the former varieties, depending on the greater functional de- 
rangement of the digestive organs, which arises during deten- 
tion. It is much more rare, and is attended with more febrile 
action and greater restlessness. The eruption appears in dif- 
ferent parts of the body in small clusters ; the pustules and the 
interstices are of a bright red. Their duration is but a few 
days, when the patches become of a yellowish brown, and sepa- 
rate. They, however, are very liable to appear in succession. 
The different varieties may at times exist together, so that it is 
difficult to tell which of them predominates. 

Strophulus is a disease of no danger, unless complicated 
with great gastric derangement, gastro-enteritis, or cerebral con- 
gestion. 

Treatment. — In general it requires but little treatment, 
further than allaying the itching and irritation by the applica- 
tion of a little vinegar and water, when these are severe. If 
the stomach is acid, a little magnesia will be needed, both to 
neutralize it and also to keep the bowels open. In more se- 
vere affections, attended with a loose state of the bowels, it will 
be necessary to combine a small quantity of rhubarb with the 
magnesia, and afterwards allaying the irritation and pain in the 
bowels by a small quantity of the camphorated tincture of 
opium, or a drop of laudanum, as already recommended when 
treating of disorders of the bowels ; the disorder, when thus 
complicated, requiring no difference in the treatment. 

Great care should be taken of the diet ; and all other food 
besides the mother's milk ought to be withheld. This should 
be particularly attended to in that form which more commonly 
attacks children during the process of teething, when a varied 



EXCERNENT SYSTEM. 359 

diet is in some degree adopted. The mildest of food, when it 
occurs towards the termination of teething, or when the child 
is weaned, must be carefully adhered to. Milk and arrow-root, 
sago or tapioca, should form the principal part of the nourish- 
ment, while the bowels ought to be kept in a free condition. If 
much febrile action exists, with an evident derangement of the 
chylopoetic secretions, a small dose of calomel, followed by 
castor oil, or the hydrargyrum c. creta, according to the existing 
indications, will be needed. The warm bath, also, is a useful 
adjunct in the treatment, especially when there exists much dis- 
order of the bowels. The gums should always be examined, 
and if found enlarged and tense, indicating the presence of 
advancing teeth, ought to be carefully cut. 

PRURIGO. 

This is a papulous disease, differing in its colour very little, if 
any, from that of the skin, and characterized by an intense 
itching. It appears either on one region of the body, from 
which it may spread to others, or it may attack several parts 
at once. 

The general characteristics of this disease, which has been 
divided into several species, from its seat, the advanced age of 
the individual attacked, or from some peculiarity in the violence 
of the symptoms, are at first a feeling of itchiness, arising from 
a great number of very small papulae, scarcely differing in 
colour from the surrounding skin. This itching increases in 
intensity until it is almost insupportable, and has been com- 
pared to the burrowing of a multitude of ants ; whence the term 
formicans, given to one species of it, is derived. These papulae 
are generally so slightly projecting as scarcely to rise beyond 
the surface of the skin. The intenseness of the itching is in- 
creased by the friction of the clothes, the warmth of the bed, 
or the excitement following a meal. 

Prurigo attacks mostly those of a delicate skin ; hence it 
occurs more frequently in females and children than among 
others. A low and damp habitation, it has been remarked, is 
greatly favourable to its production, especially when there is 
great want of cleanliness. Indigestion, arising from improper 
food, or food of too stimulating a nature, has also been observed 
to precede an attack of pruritis. 

When it occurs in children it is not very obstinate, but very 
liable to recur. 

Treatment. — If it appear to be connected with indigestion, 
the first step in the treatment is to adopt the proper measures 
for the removal of the original disease. Especially should 
children be entirely prohibited the use of spices in their food 



180 DISEASES OF CHILDREN. 

or wine, or other stimulating drink. At no age are the effects 
of stimulants so direct and so invariable in their appearance 
as in childhood ; fever and cutaneous eruptions quickly appear- 
ing after drinking a small quantity of wine. The condition of 
the bowels must be watched, and they should not be allowed 
to become constipated. The diet should be light and cool- 
ing, and whey or thin gruel ought to constitute the principal 
drinks. In severe cases, attended with evident accumulations 
in the stomach and bowels, and a deranged state of the secre- 
tions of the various glandular appendages of the digestive 
organs, an emetic will be found a highly useful remedy at the 
commencement, followed by a dose of calomel and neutral salts. 
The local applications are of great importance in the treat- 
ment of pruriginous affections ; indeed, they are indispensable to 
relieve the urgent symptoms so inconceivably distressing in this 
disease. Cold poultices, weak solutions of the acetate of lead, and 
soothing applications of the extract of hyoscyamus, will all be 
found at times necessary. A wash of acetic acid, reduced with 
water, will often allay the itching. Where the inflammation is 
very violent, it will be proper to apply several leeches around 
the inflamed part, and to encourage the bleeding in the usual way. 

IMPETIGO.— RUNNING TETTER. 

Impetigo is characterized by small pustules, appearing in 
different parts of the body, either distinct, or collected in 
groups ; the face is the part most frequently affected with them. 
At first they appear like small red spots, in the centre of which 
yellow pustules are found, which, breaking in a few days, dis- 
charge a yellow fluid, having the appearance of thickened 
honey, when dry. The discharge continuing beneath the scabs, 
causes them to increase in thickness. When these scabs sepa- 
rate, the part which they covered is left of a violet hue. 

It occurs in two forms, whence are derived the specific 
names. When the pustules are disposed in an oval or circular 
form, it has been denominated figurata ; when disseminated, it 
is called sparsa. It usually attacks children during dentition,, 
and those of a lymphatic and sanguineous temperament at a 
more advanced age. In those of a good constitution the dis- 
ease is generally slight, and its continuance seldom more than 
a month. At the period of teething, impetigo often affects the 
scalp, and from the influence of the hairs in this part, assumes 
all the forms of tinea, teigne granulee, of Alibert. 

There is some difficulty in distinguishing impetigo from other 
cutaneous affections. It is not unfrequently confounded with 
scabies, porrigo larvalis. crusta lactea, or milk scall of infants. 
It may be known from the former, by the eruption being in 






EXCERNENT SYSTEM. 86i 

patches, by the great quantity of ichorous fluid, and the rough 
and chapped condition of the skin ; the itching, also, in children 
that are old enough to understand the difference, will be found 
more of a tingling nature. From the latter it may be known 
by the greater hardness of the scabs, and in the thinness of the 
secreted fluid, which, in porrigo, is thick and glutinous ; the 
bases, also, of the pustules, are much firmer than in the latter 
affection. 

Treatment. — This disease requires the first remedial mea- 
sures to be directed to the condition of the digestive organs. 
After the bowels have been properly evacuated by some suit- 
able cathartic, a proper regulation of the diet should be adopted. 
Sulphur is a very common remedy in this disease, but has been 
too indiscriminately administered. The solution of super-car- 
bonate of potass, given with some acid in the form of an effer- 
vescing mixture, is very cooling, and well calculated to allay 
the irritation of the system, which uniformly exists in this dis- 
ease. The addition of the extract of conium has been recom- 
mended to adults, and may, in suitable doses, be used for children. 
In the forming stage of this disease, emollient fomentations are 
the best applications ; but as the disease advances, even these 
become distressing to the patient. 

When the disease resists these remedies, it will be necessary 
to resort to alterative doses of mercury, in the forms best adapted 
to children ; either the hydrargyrum cum creta, or Plummer's 
pill, with the decoction of sarsaparilla. In robust habits, a full 
dose of calomel, followed by an infusion of senna, given occa- 
sionally, will be found a useful method of treating the disease, 
the secretions being thereby much more promptly restored. 

When the discharge becomes profuse, the best applications 
are ointment of the oxyde of zinc, acetate of lead, or the white 
precipitate of mercury. Citrine ointment, or the red precipi- 
tate ointment, diluted with simple cerate, will also be found 
very useful applications, as will also ointment composed of 
calomel ; all these mercurial preparations should be cautiously 
used, especially about the face, as severe salivation has occa- 
sionally occurred, even in very young children. The mercu- 
rial applications are most useful in the dry state of the eruption. 
The ointment of the sub-nitrate of bismuth, made with two 
drachms to an ounce of simple cerate, is also a useful application. 
In cases where there existed great irritation, the hydrocyanic 
acid has been used, properly diluted, with an entire relief to 
the distressing symptoms. Mr. Plumbe, however, found its ap- 
plication followed by a considerable affection of the pulse ; it 
ought, therefore, to be used with some caution in children. 

46 



362 wrSEASJES OF CHILDREN. 



PORRIGO LARVALIS.-CRUSTA LACTEA, 

This disease has received one of its names from the peculiar 
covering which the face undergoes, from the secretion and 
drying of the puriform fluid over the face, enclosing it, as it 
were, in a mask. It very much resembles the one just descri- 
bed, both as to its causes and its characteristics. The principal 
difference is in the size of the original pustule, and the delicacy 
of the skin of infants ; the disease occurring at an earlier period 
is probably the cause. 

The appearance of the eruption varies considerably ; depend- 
ing, probably, on the violence of the original inflammation of 
the skin and the constitutional peculiarity of the child. Like 
the eruption just described, clusters of pustules arise in some 
parts of the face, and these pustules break and discharge a 
yellowish fluid, which concretes into thin scabs at first, but 
which, from the constant oozing beneath, becomes constantly 
thicker. These clusters uniting, the scabs almost cover the entire 
face, with the exception of the eyelids and nose. These scabs 
are of a light green, or yellow colour, and from beneath them 
an offensive and acrid fluid oozes. 

The disease is at times confined to the parts behind the ears, 
or around the mouth, or on the forehead or scalp, possessing 
all the marks which characterize the more extended affection. 
At other times it covers the whole body and limbs, when it 
becomes a severe and distressing affection, from the great 
itching and pain which are its attendants. There is always 
more or less fever accompanying it, and when long continued 
it is very exhausting. Great emaciation invariably follows pro- 
tracted cases of this disease. 

The disappearance of this affection is known by the lessened 
secretion of pus, the thinness of the newly formed scabs, and 
their white appearance, and from their being followed, when 
separated, by a slight desquamation ; which itself speedily dis- 
appears, leaving the seat of the disease shining, and of a rosy 
colour. 

It is much worse in children of a robust habit of body ; and 
when extensively diffused over the body is excessively distress- 
ing, from the incessant itching and pain, arising from the adhe- 
sion and forcible separation of contiguous parts, occurring from 
the glutinous nature of the discharge : the intervals of ease 
permitting the adhesions to take place in the folds of the skin, 
and the excoriations attendant on the disease causing excessive 
pain, when the child instinctively attempts to relieve its distress 
by rubbing and scratching the part. 



EXCERNENT SYSTEM. 



During the continuance of these cutaneous inflammations, it is 
very common for the neighbouring gland to become enlarged, 
and perhaps inflamed ; tumours, therefore, frequently form on 
the neck around the throat, behind the ears, etc. They are entire- 
ly independent of the existence of the peculiar temperament 
which gives rise to these glandular swellings under other cir- 
cumstances. In the present instance, it arises from the trans- 
mission of the inflammatory action along the course of the lym- 
phatics, and nothing is more common than to see the glands 
of the neck enlarged, when extensive inflammation and ulceration 
exist on the scalp. 

Treatment. — In the treatment of this affection, our efforts 
must mainly be directed to the existing constitutional plethora 
of the child ; for it is one of the salutary efforts of nature to 
relieve the system of its superabundant amount of fluid. It is a 
disease which, of itself, cannot be regarded as one of hazard, but 
as one of a critical nature, after the existence of other internal in- 
flammations. On this account, and from the frequent occurrence 
of hydrocephalus or other fatal diseases of infancy upon its 
sudden removal, great caution is to be observed in the use 
of such measures as will tend to its cure, without having pre- 
viously prepared the system to bear the change. Where nurses 
or mothers have been induced to apply local remedies for 
its speedy removal, ill, and even fatal consequences have almost 
invariably followed. It is but quite recently that a case of 
this kind came to my knowledge, hydrocephalus quickly fol- 
lowing the healing up of these eruptions, and terminating fa- 
tally in a few days. 

The first and most prominent indication of treatment is, 
therefore, to lessen the plethora, by a persevering use of diet 
containing less proportions of nutriment than usual. If the 
child be nursing, the nurse should live on lighter food than 
ordinary, take frequent aperients, and, if plethoric, ought to 
be bled. All stimulating beverages should be entirely with- 
held, while the lightest and simplest fluids should be the only 
kinds which the nurse is allowed to use for her drink. A glass of 
cold water will often be followed by a free flow of milk ; su- 
perceding entirely the necessity of stimulating articles for 
the purpose of exciting the action of the mammary glands. It 
will also be necessary to lessen the quantity of food the child 
takes, if it be partially or wholly fed with the spoon, while the 
bowels are kept actively free by means of small portions of 
phosphate of soda. 

This course should be kept up for a few days, and if an 
improvement be. not made in the appearance of the disease, 
the secretions of the chylopoetic viscera ought to be more ac- 



364 DISEASES OF CHILDREN, 

tively excited by a dose or two of calomel ; and if the child be of 
a remarkably robust habit, a minute portion of antimony may 
be added to it, proportioned to the age of the child. The 
bowels may afterwards be kept open by small doses of sul- 
phur, which should be washed and freed entirely from any acidu- 
lous matter, as the latter produces the extreme griping that 
attends the passage of sulphur through the bowels.* It may be 
combined with magnesia for effecting the same object.f All 
these means should be persevered in to a moderate extent, so as 
not to induce an excessive and morbid irritability of the mucous 
membrane of the bowels ; they may occasionally be with- 
held for two or three days, and then resumed. The bowels 
should, by these or similar means, be kept loose for two or three 
weeks, when the child will be sufficiently reduced to attempt 
the healing of the eruption by local means, if it has not already 
disappeared. 

Frequent washing of the affected parts with warm milk and 
water, or with other emollients, is by far the best method of 
managing this affection locally ; but in extremely obstinate 
cases it will be necessary to resort to other applications, which 
effect a change in the capillaries. Mercurials have, therefore, 
been resorted to, and with success ; but, as was before re- 
marked, great caution is necessary in the use of ointments, of 
which mercury forms the active ingredient, in sores about the 
face, for it is sometimes very rapidly absorbed, and inflamma- 
tion and ulceration of the salivary glands very quickly ensue. 
Where these are found necessary, the ointment of the nitrate 
of mercury, reduced with simple cerate, or the ointment of 
calomel, as recommended by Dr. Dewees, will be found the 
most useful. 

Sulphurous lotions have also been effectual when other 
remedies have failed, and are the more useful in proportion as 
the disease has extended over the body.J 

Among the remedies of a constitutional nature lately recom- 
mended for the treatment of this disease, is the syrup of aspa- 
ragus ; it would appear to be a very inert and inefficient 
remedy. 



* B; Sulphuris, gr. x. — xx. 
Mist. Acaciae, 3ij. 
Sacchar. Alb., §ss. 
Aquae Rosae, 5j M. 
A teaspoonful every hour, first shak- 
ing the vial, for an infant at the breast. 



t B; Sulphuris, 3ss. 

Magnesice Carb., 3j. 
Sacchar. Alb., 3ij. 
ft. Pulvis. M. 

Ten grains three or four times a 
day. 



B: Potassae Sulphuret., 3ij. 
Sodae Subcarb., 5ij. 
Aquas Fervent,, ftj. M. 



EXCERNENT SYSTEM. 365 

When the affection invades the scalp, it scarcely differs in 
its form from other diseases of this part, and requires scarcely 
any difference in the treatment from that adopted in the man- 
agement of tinea capitis. 

ERYSIPELAS. 

Erysipelas of young infants is a disease of very rare occur- 
rence in the United States, compared with some parts of 
Europe, especially in the hospitals, where it is a disease of 
great mortality. It appears to have been first noticed by Avi- 
cenna, who lived about the beginning of the eleventh century. 
Drs. Underwood and Garthshore have given the best account 
of this affection in modern times ; while, for a more accurate 
pathology, we are indebted to Billard and other physicians of 
continental Europe. 

Etiology and Pathology. — Billard has remarked, that this 
disease in young infants differs from that which occurs in 
adults, as it is in the latter connected with some affection of 
the digestive organs. This is no doubt correct in very young 
infants ; but in the few cases which I have seen, arising in in- 
fants of the age of two or three months, it was evidently con- 
nected with a deranged state of the chylopoetic viscera. This, 
however, cannot be regarded as a disease peculiar to children : 
that, on the contrary, which attacks them immediately after 
birth, or within a comparatively short period after birth, when 
it appears to be more particularly dependent on the great sen- 
sibility of the skin, so remarkable in the first few weeks of life, 
has something peculiar in it. A large proportion of blood cir- 
culates in the tegumentary tissue at this period, and predisposes 
the skin to take on inflammation, upon the slightest exposure to 
irritating causes. There is, also, a great disposition on the 
part of the skin to become inflamed, from having parted with 
its epidermis immediately after birth ; hence the contact of 
urine or alvine excretions is a frequent cause of this disease. 

The erysipelatous affection of the trunk is of more frequent 
occurrence than that of any other part ; and when it has ap- 
peared on the abdomen, it has been supposed to arise from the 
irritation caused by pulling the cord. The affection of the 
lower limbs is the next in order of frequency. 

Of thirty cases recorded by M. Billard, which occurred to 
him in the Foundling Hospital, there were eighteen below the 
age of six months, from one day, upwards. 

Post-mortem examinations have revealed the existence of 
enteritis more frequently than of any other visceral derange- 
ment. In other instances the disease has been traced to the 
umbilical vein, which, with the peritoneum around it, has been 



366 DISEASES OF CHILDREN. 

discovered severely inflamed, arising, no doubt, from injury done 
to it when tying it, as above mentioned. Such cases are uni- 
formly found in young infants, where the inflammation has inva- 
ded the abdomen and lower extremities ; and, when arising from 
this cause, always makes its appearance before the separation 
of the cord, or about that period. The vein has, in some in- 
stances, been found in a state of suppuration, from which it seems 
natural to infer that in such cases the inflammation had its 
origin there. 

In older children, there is almost always, as in adults, func- 
tional derangement of the liver and stomach, and, indeed, in 
them the disease can differ but little from that in adults. In 
young infants, being an affection principally of the skin itself, 
and not a sympathetic disease, its severity and tendency to 
disorganization must be much greater, and its danger more 
imminent. 

Semeiology. — The first appearance of the disease is in 
red spots, which spread irregularly, but gradually extend from 
the part on which they first appear, which is usually about the 
region of the umbilicus or groins, until it covers the whole of 
the inside of the thighs and abdomen. In general there is 
much heat and tumefaction, with a feeling of hardness, having 
more the character of the phlegmonoid variety. Such at least 
appears to be the nature of the disease in ,the United States. 
This character is more marked in older children, when the 
disease is not confined to the parts just mentioned, but will 
more frequently occur in the superior extremities and face; 
often commencing with an inflammatory blush in the hands. 
When it extends to the neck, it is very likely to form an abscess 
in that part. There is great heat of skin, and apparently much 
suffering from itching or stinging which the disease produces, 
judging from the extreme restlessness and cries of the child. 
The pulse also indicates considerable action in the arterial 
system. 

In very young infants, and especially among those who 
breathe the impure air of crowded hospitals, there is a great 
tendency to vesication and sphacelus. The vesicles have 
a livid appearance surrounding them, and the tendency to dis- 
organization is very rapid. This form, which may be regarded 
as one of decided debility, and different from that above 
mentioned, which is the acute inflammatory disease, has all the 
symptoms denoting the rapid loss of vital energy in the capilla- 
ries of the affected part, which appear unable to sustain the 
increased action imposed on them from their constitutional 
weakness. 

Besides these local evidences of extreme debility, the general 



EXCERNENT SYSTEM. 367 

system shows the deficiency of energy, in the absence of the 
full developement of febrile action. There is but little heat on 
the surface after the first manifestation of the disease, and but 
little force in the pulse. This constitutional debility increases 
with the progress of the disease. 

Treatment. — In the ordinary, or acute form, it is obvious 
that an antiphlogistic course is that which promises most pros- 
pect of success ; but in this disease, even with the evidences of 
much arterial action, bleeding cannot be resorted to without 
hazard ; great circumspection will therefore be necessary, even 
should the symptoms appear imperatively to demand the loss of 
blood. When the skin is superficially inflamed in young infants, 
the effect bears some analogy to the influence of a burn, in ra- 
pidly exhausting the vital energies ; it is therefore with great 
caution that any course should be adopted which is calculated 
to increase the tendency to debility. The bowels should be 
opened with some laxative, and followed by simple diaphoretic 
medicines, of such a nature as will not, by their nauseating effect, 
increase the prostration. The liquor ammonias acetatis is a good 
preparation for fulfilling the latter indication. In children two 
or three months of age, the disease is almost invariably attended 
with some hepatic congestion, and requires more active mea- 
sures. A small quantity of calomel, combined with rhubarb, 
will be necessary for the complete evacuation of the bowels, 
while the union of the bi-carbonate of potash will at the same 
time both destroy the acid, which almost always exists in the 
stomach of young children in excess, and will, by its sedative 
effects, allay the irritation of the mucous membrane of the sto- 
mach and bowels.* The operation should be promoted by ene- 
mata. Mr. Lawrence advises calomel and James's powder, in 
the proportion of one fourth of a grain of the former with a 
sixth of a grain of the latter, three or four times a day. Where 
there is much prostration, it is evident that antimony in any 
form should be avoided. In the acute or phlegmonoid erysipelas, 
this objection, however, does not exist, especially to the mild 
form of James's powder. Dr. Eberle is of opinion that emetics 
would be a useful course to adopt in some instances in this dis- 
ease, from having seen the good effects which followed the 
accidental operation of calomel and ipecacuanha in a child 
about a month old. When there is much excitement, and at- 

* ~fy Hydr. Subm. 

Pulv. Rhei, aa. gr. vi. 
Potassse Sup. Carb., gr. xii. 
Sacchar. Alb., 3j. M. 
Divid. in Pulv., No. xii. 
A powder every three hours to a child of two months, until an effect is produced. 



368 DISEASES OF CHILDREN. 

tended with an evident morbid state of the biliary secretion, 
an occasional mild emetic will unquestionably be useful, but 
is hardly admissible in the disease, as it occurs in very young 
infants, in whom it is generally local in its origin. 

With respect to local applications, great difference of 
opinion exists. Burns considers the application of cold water 
as the best to allay the inflammation, and that the danger arises 
from the constant application of very cold water, whereby a 
dangerous metastasis, or extreme local debility is produced. 
Drs. Eberle and Dewees consider such a course as generally 
inadmissible in this form of inflammation, and regard the use 
of saturnine washes as a measure of doubtful utility ; the 
latter, especially, recommends the tincture of camphor as the 
best application. This is unquestionably the best that can be 
used ; for simple erysipelatous inflammation will not endure 
either the sudden abstraction of heat nor the sedative effects 
of lead. The evaporation of the spirits will lessen the heat, 
while the gently stimulating qualities of the camphor modifies 
the debilitating effects which would arise from the too great 
depression of the local action. 

Blisters, as recommended by Drs. Physic and Dewees, I 
have used with decided advantage when the inflammation was 
spreading, by applying them near the margin of the affected 
part on the sound skin. They appear to act by producing a 
new action in the capillaries of the part, and also by the local 
depletion from these vessels. Mercurial ointment has also 
recently been used, and Dr. Dewees speaks of the good effects 
which have followed its application, and directs it to be applied 
to the inflamed margin and a portion of the sound skin during 
the stage of inflammation, and also during the period of vesi- 
cation, first taking the precaution of opening the vesicles. The 
ointment is applied to the sound skin when the blisters have 
opened of themselves, and become encrusted with a scab, or 
where parts of the affected skin have suppurated. Where there 
is a tendency to sloughing, the application of yeast, or chloride 
of soda, in the form of a poultice, or a decoction of bark, may 
be used in the same manner. 

During the process of sphacelation, the strength of the child 
must be supported by tonics, and the sulphate of quinine 
appears to exert a more beneficial effect on children than tonics 
of any other description, probably from the rapidity of its- 
action. At the same time the excess of irritability must be 
controlled by the administration of some anodyne, as a drop of 
laudanum, repeated as occasion may require. The carbonate 
of ammonia is recommended by Burns as highly beneficial in 
this disease, when attended with great prostration. Untoward 



EXCERNENT SYSTEM. 369 

symptoms arising during the progress of the disease, must be 
treated according to the principles already laid down when 
speaking of other affections of children. Diarrhoea should be 
immediately arrested by proper absorbent and anodyne reme- 
dies. For a young infant, a week or a fortnight old, the following 
prescription may be used.* Wine whey ought at the same 
time to be given to the child when much prostrated. 

JAUNDICE.- YELLOW GUM. 

This is a yellowness of the skin, which comes on three or 
four days after birth, and in the greatest number of instances, 
without any indisposition. Under these circumstances it is 
independent of any hepatic derangement, but arises from some 
alteration in the serum of the blood, analogous to the change 
which is observed to take place in a bruise, when the more 
limpid parts of the effused fluid have been absorbed, leaving the 
colouring matter of the serum behind ; or to the simple increase 
of the natural colour of the serum, perhaps from the bile. This 
opinion is held by Sauvages, Cullen, Billard, and others. It 
has been, on dissection, noticed that other parts of the body, 
besides the skin, are tinged with yellow, such as the brain, 
kidneys, muscles, and cellular tissue, although the external tegu- 
ments are the most ordinary seat of the affection. The orange 
colour, which characterizes the disease, follows the high red so 
common in young children, in a very gradual manner, and ac- 
cording to M. Billard, is the intermediate hue between the pri- 
mitive red and the delicate rosy hue, or the permanent white 
of a child's complexion. It may be observed to exist when 
the finger is pressed on the skin so as to remove the blood ; 
the skin then exhibiting a yellow tinge instead of white, show- 
ing its dependence, in some degree, on the quantity of blood 
circulating in the tegumentary tissue. 

This form of jaundice is very short in its duration, and scarcely 
requires any treatment ; for the infant exhibits in general no 
indisposition beyond this simple alteration in the colour of the 
skin, the digestion being unimpaired, and the alvine discharges 
containing a sufficient quantity of bile. So common is it to 
new-born infants, without any manifestation of sickness, that it 
has been regarded as natural to man, and a condition arising 
from ihe necessary changes which the circulation undergoes 
at the time of birth. 

* ty. Cretse pp., 3ij. 

Tinct. Opii., gt. x. _ 
Syrup. Simplicis., § ss. 
Aquae Anisi., §j. M. 
A half a teaspoonful every two hours until relieved. The dose may be increased 
according to the age of the child. 

47 



370 DISEASES OF CHILDREN. 

This, however, is not the case with the other form of the 
disease, which may, in strictness, be called jaundice. In this 
there is a yellowness of the tunica sclerotica, which in the for- 
mer does not exist. There is, also, indigestion and absence 
of bile in the stools, some degree of drowsiness, and in severe 
cases, more or less fever. When, therefore, these symptoms 
exist, and there is also a yellow tinge in the excretions, it will 
be necessary to resort to therapeutic measures, the disease 
being essentially different from the former. It therefore re- 
quires a more particular notice of its causes, symptoms and 
treatment. For a full description of infantile jaundice we are 
indebted to Dr. Baumes, # who has given the most correct ac- 
count of the affection. Before his time the ideas of its nature 
were very vague and indistinct; but his investigations have 
shown that it is produced by various causes which very mate- 
rially control the treatment. 

Etiology. — The causes of jaundice in young infants are va- 
rious, but the most common is the retention of the meconium. 
Next to this is the irritation from indigestion of milk, and the 
presence of the curds and other results of chemical decompo- 
sition, spasm or malformation of the bile ducts, viscid condi- 
tion of the bile, the sudden impression of cold air on the skin, 
producing congestions and inflammation of the liver. Various 
other causes have also been assigned for the production of 
this disease, which it is needless to mention. Some are only 
remarkable for their fanciful hypotheses, such as the putre- 
fying of the blood in the umbilical cord. It has been supposed 
also to arise from the compression of the brain in long and 
tedious labours. But it is more probable that the arrest of 
circulation through the cord during difficult labours, has pro- 
duced a congested state of the liver. This cause may be sus- 
pected when the child has been born with the usual ap- 
pearance of a general congestion of the system, and an arrest 
of the circulation, causing a livid condition of the whole sur- 
face of the body, and the usual symptoms attending asphyxia. 
It is certain that proper nourishment is one of the best preserva- 
tives from infantile jaundice, for it is ascertained that by far the 
greatest number of those attacked are such as have not the 
advantage of the mother's milk, but are suckled by hired nurses. f 

Semeiology. — In jaundice, the skin, conjunctiva, tongue and 
mouth, all present the peculiar hue which distinguishes this 
disease, and dissection has traced it to the cellular tissue, and 

* Trait£ de l'lctere ou Jaunesse des Enfans, par G. B. T. Baumes, M. D. j 
Paris, 1805. 
t Capuron, Op. Cit. p. 201. 



EXCERNENT SYSTEM. 371 

even the abdominal viscera. The colour varies from a bright 
to a greenish yellow, while the urine is tinged with the same, 
and the linen died with a saffron colour. The alvine discharges, 
also, contain at times a superabundance of bile, and again 
are whitish, and destitute of the usual colouring matter ; both 
conditions showing a derangement in the action of the liver, or a 
morbid condition of the duct transmitting the bile. 

These are the general symptoms of jaundice ; as to the 
others, they vary according to the cause producing them. When 
it arises from a spasm of the gall ducts, it appears suddenly, 
with tenseness of the abdomen, nausea, and pains bearing some 
resemblance to colic. Pain in the right hypochondriac re- 
gion, with enlargement, great restlessness and fever, are the ac- 
companying signs of jaundice from inflammation of the liver. 
A torpid condition of this organ may be known by the gradual 
enlargement of the region which it occupies, without much ac- 
companying fever, a defective appetite, slowness of the bowels, 
and emaciation. 

From the causes, which have all their peculiar signs, may 
the prognosis be formed with some degree of accuracy ; for 
if it be connected with the simple alteration of the serum, as is 
noticed above, constituting the yellow gum of children, it 
needs no interference of art, for it will uniformly disappear of 
itself. So, also, if it appear to depend on the retention of the 
meconium, or on the presence of partially digested milk, or any 
other simple irritating cause, it will easily be removed, and can- 
not be regarded as a disease of danger. On the contrary, it is 
attended with much more danger when arising from a spasm 
or inflammation of the bile ducts, or inflammation of the duo- 
denum or liver ; indeed, it is under such circumstances alone 
that the disease can be regarded as one which may become 
fatal to the child. 

Treatment. — The treatment of this disease of course varies 
according to the nature of the cause. If it arise from the 
simple retention of the meconium, a small quantity of castor 
oil will be necessary to remove it, and will be all that the dis- 
ease will require. If it persist, and if attended with the ordi- 
nary symptoms of infantile indigestion, it will be necessary to 
change the nurse, should the child be nourished by a wet nurse ; 
or her milk may be rendered slightly purgative by the use 
of mild saline cathartics. The frequent use, also, of manna, 
will tend to the removal of the irritating cause of this affection. 
It is a mild and unirritating laxative, admirably calculated for 
young infants, and may be given to them dissolved in milk 
or whey. A strict and close attention to the diet of the nurse 
will be absolutely necessary, for the proper management of the 



S72 DISEASES OF CHILDREN. 

disease, when it is evidently attended with acidity, colic pains 
and curdy stools. All crude and ascessant articles of food 
must be prohibited ; and especially all spirituous potations, as 
milk punch, beer posset, etc., so frequently resorted to for the 
purpose of increasing the quantity of milk. One great cause 
of disordered digestion, from the bad qualities of the milk, is 
the anxiety arising from mental distress. A nurse, depressed 
by grief or uneasiness, can seldom afford proper nourishment 
for the child ; hence the great danger arising from employing 
hired nurses, whose necessities alone compel them to resort to 
the task of suckling infants. This is one of the strongest rea- 
sons for a mother to shun, if it be possible, the danger that may 
arise from having a substitute. No law of our physical nature 
can be broken without endangering our physical existence. In 
infancy, where the closest observance of these laws is the most 
necessary, an infringement of them is attended with propor- 
tionate hazard. 

In connection with this, alkalies will also be found beneficial 
not only in correcting the acidity which uniformly attends indi- 
gestion of infants, but also in soothing the irritated mucous 
membrane of the stomach and bowels. The sesqui-carbonate 
of potash is particularly beneficial in allaying the morbid irrita- 
bility of the mucous membrane of the stomach and duodenum, 
for experience has often satisfied me that it exerts a decided 
sedative effect on this irritated membrane, while the peristaltic 
action is not arrested. It may be given in doses of from two 
to ten grains, two or three times a day, combined with mucilage, 
a little sweetened. This will be the most convenient form of ad- 
ministering it to young infants. 

Besides simple indigestion, the disease will be at times con- 
nected with an inflamed state of the gastro-duodenal mucous 
membrane, which is but the sequel of ordinary functional dis- 
order ; and when the disease has terminated fatally is uniformly 
found to exist, together with an inflamed and tumefied condition 
of the bile ducts. This state may, with careful examination, 
sometimes be ascertained, although it is in general a very dif- 
ficult thing to make an accurate diagnosis in young infants in 
a disease of this nature. The preceding symptoms, the persist- 
ence of the disease, together with the manifestation of pain 
on repeated attempts on pressure to discover the precise seat 
of the irritation, will enable the physician to form a reasonable 
presumption of the existence of inflammation in the neighbour- 
hood of the duodenum. Where this inflammation is present 
there is also more or less sickness, with vomiting of thin mu- 
cus, together with the undigested milk. The treatment under 
these circumstances need differ but little from that just recom- 



EXCERNENT SYSTEM. 373 

mended, with the addition of a small blister over the epigastric 
region. 

A higher degree of inflammation, and the extension of it to 
the liver, will be marked by the presence of a much greater 
degree of fever. When this exists, a few leeches may be ap- 
plied to the anus, or over the right hypochondrium, followed 
by a soft poultice. The general restoration of the secretory 
function of the skin may also be attempted by the use of the 
warm bath. Calomel and ipecacuanha will be necessary in 
this condition of the system, to control the inflammatory and 
febrile action ; the direct effects of these agents over the secre- 
tions make them important means, when combined, to overcome 
the inflammatory action of the liver and the accompanying 
fever.* The administration of these powders should be fol- 
lowed by a suitable dose of castor oil or a common enema* 
This course must be steadily pursued, until the secretions of the 
liver and intestines are* fully affected, and the alvine evacua- 
tions exhibit a healthy secretion of bile. In great irritability of 
the stomach, forbidding the use of calomel and ipecacuanha, 
mercurial ointment may be applied to the skin covering the 
region of the liver. In the tender condition of the skin in in- 
fancy, this method of applying mercury externally is better 
than either friction or by means of a plaster, which must be 
made to adhere before any advantage can be derived from it, 
thus causing great cutaneous irritation, and probably excoriation. 
Mercury in some form must be our main dependence in the 
management of this variety of jaundice, assisted in its opera- 
tion by some mild laxative. 

In cases connected with a torpid condition of the liver, known 
by the gradual progress of the disease unaccompanied by any 
fever, but attended with an enlargement of the right side, and 
the absence of bile in the stools, emetics have been advised, to 
rouse the action of the hepatic system,f and relieve the con- 
gested condition of the liver by determining the blood to the 
surface. This course, however, is rarely necessary in young 
infants, as the object can be accomplished in another manner, 
without the risk which will attend the action of an emetic, 
should an error in the diagnosis occur, and the affection be in 
reality connected with an inflamed state of the duodenal mucous 
membrane. The nice discrimination is a very difficult matter in 

* fy Hydr. Subm., gr. ij. 

Pulv. Ipecac, gr. j. 

Sachar. Alb., gr. x. M. 
Divid. in Pulv., No. 6. 
One powder every two hours, 
t Eberle, Op. Cit., p. 104. 



374 DISEASES OF CHILDREN. 

infants, and an error had better be committed on the safe side. 
The free employment of calomel will be applicable to the con- 
gested and torpid condition of the liver, and the warm bath will 
essentially aid in the relief of the internal congestion. A mild 
emetic will nevertheless be useful, where there exists unequivo- 
cal evidence of the absence of an inflammatory action. The 
syrup of ipecacuanha will be the best for this purpose. 

In those cases attended with violent colic pains, tension of 
the abdomen, and other evidences of spasm of the bile ducts or 
of the small intestines, the warm bath, emollient fomentations, 
with antispasmodic enemata, consisting of a weak infusion of 
poppy heads or assafcetida, will be among the most useful re- 
medies.* Frictions with the hand over the abdomen will also, 
under these circumstances, be attended at least with a relief to 
the urgent symptoms. Anodynes and antispasmodics, as recom- 
mended for colic, will also be necessary, provided they do 
not interfere with the action of laxative medicines. A regu- 
lar action of the bowels, and a strict attention^to the state of 
the digestive organs, especially the destruction of the acid 
contained in the stomach, is the most proper course to be 
adopted in chronic cases. In such cases, also, the leonto- 
don taraxicum, or dandelion, has been found to be a very effi- 
cacious remedy, and has been long in use, from its influence 
over the biliary secretion. In spasmodic cases it may be com- 
bined with an infusion of hops. For the purpose of preserving 
the free condition of the bowels, it should be combined with some 
laxative, as in the subjoined formula, f It is a very valuable 
medicine, and is useful in relieving abdominal congestions, from 
its action on the biliary and urinary secretions, on which pro- 
tracted jaundice often depends. 

FROM GASTRO-ENTERIC IRRITATION AT ALL PERIODS. 
URTICARIA.-NETTLE-RASH. 

Urticaria is an exanthematous inflammation, characterized 
by the eruption of small spots or wheals, transient in their 
duration, either paler or redder than the surrounding skin, re- 
sembling, both in appearance and the sensation they produce, 
the stinging of nettles. Urticaria is generally preceded by 
some febrile symptoms, which, in severe cases, are continued 
through the progress of the eruption. 



* R Assafcetida, gr. vj. 
Infus. Anthemidis, £j. 
Acacia, q. s. M. 
Sit enema. 



t R Ext. Taraxici, gr. xx. 

Conf. Sennae, 

Sodee Sesqui-Carb., aa. gr. v. 

Aquae, §j. M. 
A teaspoonrul three or four times a 
day. 



EXCERNENT SYSTEM. 375 

There are several species of this disease, which it is unne- 
cessary here to enumerate, as works devoted exclusively to 
diseases of the skin will necessarily be consulted, where full 
information is sought on the subject. It will suffice to refer 
here to those forms which are common to children, and by a 
consideration of their cause, simplify the subject, to bring it 
within the scope of the present work. 

The first symptoms of common urticaria, arising from indi- 
gestion, in consequence of eating certain fishes, mushrooms, 
honey, various kinds of fruit, usually show themselves in an hour 
or two after the ingestion of the substances causing the disease. 
There are at first much nausea, weakness and giddiness. The 
skin is burning hot, when blotches of a whitish appearance, of 
different sizes and shapes, appear on the shoulders, loins, arms, 
and about the knees. These elevated spots are surrounded by 
a red areola, and are extremely distressing, from the incessant 
itching and stinging sensations they produce, which are greatly 
increased in bed. 

In severe cases these spots are often preceded by vomit- 
ing, and sometimes by purging. These symptoms usually 
attend urticaria from the ingestion of poisonous articles of food, 
and of some medicines ; and usually occur in older children, 
in whom the causes and symptoms are similar to those occur- 
ring in adults. 

There is another form, which is occasionally attended with 
fever, not unfrequently attacking children that are teething. 
It often continues a long time, with symptoms like those already 
mentioned ; but the eruption may suddenly disappear, so that 
it is difficult to discover any thing of it on searching over va- 
rious parts of the body. It will, however, as quickly re-appear, 
sometimes in the same place, and sometimes in another, with- 
out any assignable cause. In these instances it is unattended 
with vomiting or purging. 

The latter form, besides the irritation of the system produ- 
ced by teething, appears to depend on a chronic disorder of the 
digestive organs, or on an inflammation of the mucous mem- 
brane of the stomach, in children who possess much of the 
sanguineous and nervous temperament. It will, therefore, be 
found to be occasionally a very protracted affection, lasting for 
weeks, and even for months ; disappearing altogether for a day 
or two, and appearing again on the slightest excess of food, or 
a sudden exposure to a change of temperature. 

Treatment. — Where the disease has been produced by the 
ingestion of some poisonous substance, its immediate ejection 
by a mild emetic, assisted by warm fluids, is needed. Nature 
generally excites vomiting, and frequently purging ; the former 



376 DISEASES OF CHILDREN. 

should be promoted by copious draughts of warm water, until 
the offending substance has been entirely removed. A sufficient 
dose of castor oil ought also to be given, that the bowels may be 
freely moved. It will, for the most part, entirely disappear on 
the removal of the irritating cause ; but a warm bath may 
sometimes be required to assist in restoring the proper secre- 
tory action of the skin. 

In the other form of the affection, where it is independent of 
the action of an irritating substance received into the stomach, 
an examination for the cause will be necessary, as it may arise 
from different conditions of the stomach, as well as from the 
irritation of teething. Sometimes it is attended with much 
fever; the state of the fauces and epigastrium should then 
be examined by gentle pressure, if the former be found 
inflamed and the latter tender; or if one or the other states 
exist, an inflammation of the mucous membrane of the sto- 
mach is doubtless present, and the case should be treated either 
by bleeding from the arm, or by the application of leeches 
over the region of the stomach. The food ought to be re- 
stricted to the mildest and least irritating kind, while the bowels 
are kept free by emollient enemata. As a local application, 
vinegar and water, or a solution of the sub-acetate of lead, will 
be the best to allay the itching and stinging pain attending the 
eruption. The latter, however, should be cautiously used, as 
the surface affected is generally extensive, and a free use of it 
would perhaps be attended with very serious consequences. 
In teething children the gums must be examined, and if swollen, 
freely cut. 

Besides an inflammatory condition of the gastric mucous 
membrane, a constant state of irritation from the presence of 
acid, or the uninterrupted use of some one article of diet, may 
keep up the disease for a long time. A little careful attention 
to the symptoms will detect the presence of the former ; and 
an entire change in the diet of the patient will not only discover 
the cause of the long continuance of the disease, but will also 
prove the best remedy for its removal. A regular condition 
of the bowels should be preserved by the use of magnesia, or 
magnesia and rhubarb, and the superabundant acid be neu- 
tralized by frequent use of alkalies. 

LICHEN. 

Lichen scarcely, if ever, occurs in infants at the breast, but is 
peculiar to children from five years and upwards, and also to 
adults. It is a papulous disease, and characterized by a 
successive eruption, of a reddish colour, in different parts of 
the body, and, occasionally, by its simultaneous appearance 



EXCERNENT SYSTEM. 377 

over ail parts. It generally terminates in a furfuraceous sepa- 
ration of the cuticle. 

Several forms of this disease are described by authors, but 
their essential features are the red and inflamed papulae, which, 
in the simplest form, appear on the neck, face and arms, 
either attacking these parts simultaneously, or spreading from 
one to the other. It is generally very troublesome, from the 
tingling or itching sensation it produces, but is rarely attended 
with any febrile action. 

The most common form of lichen among children is the 
lichen tropicus, or prickly heat, which, indeed, includes all 
the others, but modified by atmospheric heat. It appears 
always to be attended with an excited state of the liver, so 
common in warm seasons. The eruption which appears in 
the heat of summer consists of a great number of small circu- 
lar papulae in different parts of the body, but more especially 
on the back of the neck and shoulders, greatly increased in 
redness when the circulation is excited from any cause. It is 
never attended with danger, unless suddenly arrested by the 
application of cold. The itching and restlessness it occasions are 
extremely annoying, often utterly depriving the child of all 
sleep, and increasing when the child is warm in bed. 

Treatment. — The cooling system is the best method of 
treating prickly heat. Every thing of a heating nature must 
be avoided ; the clothes should be light, and all exposure to the 
sun and heat ought to be carefully avoided. This, with some 
mild purgative, will, in the greatest number of instances, be all 
the treatment required . Where the disorder is of great severity, 
cooling washes of vinegar and water will be found to allay 
the extreme itching. Acidulated drinks ought, also, to be libe- 
rally used in older children. The common beverage of cream 
of tartar affords an excellent cooling drink, gently affecting the 
bowels, and when sweetened sufficiently, is very acceptable to 
children. It is rarely necessary to resort to any other measures 
for the relief of this disease ; but if it should increase in inten- 
sity, or if coma or other evidences of internal congestion appear, 
the system must be relieved by bleeding, and the warm bath 
must be resorted to. 

ROSEOLA.— ROSE-RASH. 

This is a superficial inflammation, often bearing a great re- 
semblance to other inflammations of the skin, and not unfre- 
quently an attendant on other eruptive diseases, as variola, 
vaccinia, etc. 

The inflammation is characterized by the existence of patches 

48 



378 DISEASES OF CHILDREN. 

of irregular rose-coloured inflammation, attended with great 
itching. It is rarely followed by a desquamation of the cuticle. 

It is very common in infants ; attacking them mostly in the 
summer and autumnal months, and arises principally when they 
are teething, and appears to be at times connected with an acid 
or irritable condition of the bowels. 

The duration of roseola is generally short ; but in this respect 
it often varies, while it appears and disappears several times in 
the course of the day. There is at times fever attending it ; 
but in the greatest number of instances there is neither fever, 
nor any other derangement of the digestive organs, than the 
presence of a slight acidity. 

Treatment. — It scarcely requires any other treatment than 
incising the gums, a proper attention to the condition of the 
primae vise, and the preservation of the skin cool during the 
hot months. When complicated with other affectiuns, these 
demand the principal attention. Cerebral congestion is the one 
most to be apprehended, and must be met agreeably to the gene- 
rally established principles laid down for its treatment. 

ECZEMA. 

A vesicular inflammation, known at its commencement by 
the existence of small vesicles closely crowded together, accom- 
panied with considerable tension, and a circular redness of the 
skin, characterizes eczema. The fluid they secrete is some- 
times absorbed, and sometimes exuded by a rupture of the ve- 
sicles : a continued oozing then takes place, forming superficial 
scabs ; the epidermis is at the same time extensively destroyed. 
When these scabs are thrown off, the part which they covered 
exhibits a pink hue ; a new crop of vesicles forms in their place, 
following the course of that which preceded. This eruption 
shows itself in a distinct form, on the face, limbs, and upper 
part of the thighs. 

Eczema often becomes chronic in its character, when the 
different layers of the skin are involved. The inflammation 
is then severe, and deep chaps are sometimes formed in 
the skin. It is more common, however, to find an increased 
quantity of sero-purulent matter secreted, having the appear- 
ance of a blister in a state of suppuration. 
r In chronic cases where the inflammation is not so great, 
there is less sero-purulent matter formed; the scabs are, at 
first, moist and thick, and are immediately reproduced after 
being detached, but become thinner, and assume the form 
which has been described under the name of dartre squameuse. 

In the first mentioned chronic form it is a disease of great 
obstinacy, there being a continued succession of vesicles mul- 



EXCERNENT SYSTEM. 379 

tiplying and blending together, and a great abundance of secre- 
tion ; the itching and distress are intense, and great emaciation 
and derangement of the digestive organs accompany it, very 
seriously undermining the health of the patient. 

This disease much more commonly attacks youth and chil- 
dren at the age of three or four years, than infants, although 
the latter have been known to be affected very shortly after 
birth, when the disease is not unfrequently mistaken for a syphi- 
litic eruption. In new-born infants it is also apt to appear 
around the umbilicus. It also appears during the time of teeth- 
ing. It is very common for this disease to alternate with an 
inflammation of the mucous membrane of the stomach, or to 
exist simultaneously with this condition of the part ; and an 
inflammation of the mouth, bearing the characteristics of ecze- 
ma, is not uncommon in children. 

Treatment. — When eczema occurs in the face and head, it 
is decidedly a salutary eruption, especially during dentition. 
It will, therefore, be hazardous to attempt its removal in any 
other way, than by relieving the state of the system on which 
it appears to depend. The gums should be freely cut where 
there exists evidence of the pressure of the protruding teeth. 
As it is connected with a disordered state of the digestive or- 
gans, a change of the nurse has been known to effect a cure. 
In older children, a strict attention to diet will be requisite, 
while small doses of some mercurial preparation will be neces- 
sary to unload the congested viscera, and to preserve a free 
secretion from the chylopoetic viscera. Purgatives, also, form 
an important class of remedies in the treatment of eczema of chil- 
dren. As to local applications, there is nothing so effectual as a 
solution of alum, applied to the parts where the vesicles are about 
rising, the whole of the subsequent condition depending on these 
vesicles, which appear to be connected with a relaxed state of the 
capillaries ; if they are arrested in their formation, the subsequent 
stages do not take place. This, or some other astringent wash, 
I have found the best application in the treatment of the inci- 
pient stage of the disease. Mr. Plumbe recommends alum, the 
acetate or sulphate of zinc, or spirituous lotions, as the best re- 
medies in the relaxed state of the vessels after the long con- 
tinued excitement, and condemns every description of greasy 
application. The sulphur baths, in every form, I have tried 
without any success whatever ; sulphur internally, also, with- 
out any benefit. Tepid sponging of the body is very useful 
after the scabs are formed, and assists in their removal ; but 
no other advantage appears to be derived from its use. 

Where there is much pain, fomentations of the decoction of 
flaxseed or marshmallows will be found beneficial, and particu- 



380 



DISEASES OF CHILDREN. 



larly if a small quantity of poppy-heads be added to the decoc- 
tion. One of the most troublesome forms of the disease is 
where it attacks the genital organs. Owing to the extreme 
sensibility of the part, these emollient applications are extreme- 
ly soothing, and especially fomentations composed of milk and 
water. The hip bath, also, will afford great relief in cases of this 
kind, especially when extending over the nates. Emollient 
poultices are also useful to soften the indurated scabs, which, 
from their mechanical irritation, greatly add to the existing 
inflammation. 

In those chronic cases where the disease only passes through 
its stages of vesicular formation and desquamation of the cuticle, 
gentle stimulants have been used with advantage, in order to 
change the action of the cutaneous vessels. Solutions of nitrate of 
silver, sulphate of copper and diluted muriatic acid, have been 
used for this purpose. They are not, however, to be rashly used, 
without a full trial of those that are of a soothing nature. 
Ointments, composed of the oxyde of zinc, or the proto-chloride 
of mercury, have also been employed with advantage in such 
cases, when protracted. 

HERPES. 

This is an eruption of a number of vesicles, of different sizes, 
from the most minute, situated upon a red or inflamed surface. 
They are seen on the lips of persons recovering from an attack 
of fever, which are on that account designated by the specific 
term labialis. These vesicles afterwards present an exco- 
riated surface, which is covered with a yellowish scab, and 
are found in various parts of the body. 

The attention is first directed to the part, from the existence 
of a heated or tingling sensation. The part, on examination, 
exhibits a slight redness, in the midst of which several small 
vesicles appear. Near to this will be found another small 
patch of redness, and another cluster of vesicles. Thus, several 
will be found in slightly different states of advancement. These 
vesicles in a short time mingle together, shrivel, and degene- 
rate into scabs of a brown colour. In a week or fortnight the 
scabs fall off, leaving the skin tender and red. A succession 
of these clusters of vesicles sometimes appear in an irregular 
line, which, when it occurs on the body, apparently surrounds it 
in the form of a belt ; whence the term shingles, from ceingle, 
is derived — herpes zoster of nosological writers. Other differ- 
ences occur, which it is unnecessary to particularize in this work, 
as the disease is not peculiar to children, although some of its 
forms are met with, even in infants, in common with adults. 
The circular form known as the ring- worm, is probably that 
which is of most frequent occurrence in children. 



EXCERNENT SYSTEM. 381 

Herpes is difficult to cure ; and, indeed, it is hazardous to at- 
tempt to repel an eruption, which, for the most part, has been 
preceded by some febrile action, and often appears to be criti- 
cal. The violent heat and itching may be relieved by soothing 
and sedative applications, such as solutions of acetate of lead, 
with a little opium, where these are great, or emollient fomenta- 
tions. A constant attention should be paid to the condition 
of the bowels ; and frequent saline cathartics ought to be 
administered, while the diet should be of an antiphlogistic 
nature. 

In long continued local diseases of this nature, where there 
is but little constitutional affection existing, as in the common 
ring-worm, after the administration of a cathartic, and the 
proper regulation of the diet, stimulating applications may be 
used : such as the escharotic juice of the walnut, or a decoc- 
tion of dulcamara, or of any of the species of rhus or sumac. 
For effecting the same object, a solution of the sulphate of cop- 
per, or the yellow wash, has long been in use, and is highly 
useful in removing these slight affections, which are frequently 
unattended with the presence of many vesicles. 

PURPURA. 

An extravasation of blood beneath the cuticular surface, is 
the characteristic of this disease. Sometimes it appears in the 
form of minute spots, resembling the punctures of small insects, 
which vary from this size to half an inch in diameter, denomina- 
ted purpura simplex. These are at times preceded by circum- 
scribed spots or wheals, resembling urticaria ; hence the variety 
purpura urticans. Any form of the disease, when severe, may 
terminate in hemorrhage, constituting purpura hemorrhagica. 

Etiology and Pathology. — Purpura is in general connected 
with a debilitated state of the system, although it has at times 
been found to be dependent on an opposite condition. It will, 
therefore, for the most part exist where the constitution is im- 
poverished for the want of proper food ; hence it is most fre- 
quently found among the children of the most impoverished. 
Any derangement of the digestive organs, by impairing the 
quality of the chyle, and thereby affecting the constituents of 
the blood, will, in some constitutionally predisposed children, 
produce this affection with remarkable quickness. I once 
knew a child of three years of age, who was suddenly covered 
with dark purple spots in the midst of the wheals of urticaria, 
from eating inordinately of Indian corn.. They appeared with 
all the suddenness which so often marks the eruption of urti- 
caria from undigested food. From the influence of the ab- 



382 DISEASES OF CHILDREN. 

sorption of bile into the system, thus depriving the food of the 
mixture of bile, whereby the due elaboration of chyle does not 
take place, the same condition of the blood occurs ; hence it 
has been seen to accompany jaundice, of which complication 
Dr. Elliotson has recorded two cases. That this is the patho- 
logical condition, appears from a case which I recently saw in 
an infant, who died at the age of six weeks, after a severe 
jaundice, accompanied with hemorrhage from different parts of 
the body from small spots, without any abrasion of the skin, 
where dissection revealed the entire absence of the gall duct, so 
that no bile whatever was received into the intestines. 

From the analogy of the disease to scurvy, and the fact that 
children who are much fed on salted meat or fish, as is noticed 
by Dr. Graves,* and that those who live also in damp, close and 
impure places, and the connection of the disease with a deficient 
supply of bile into the intestines, all of which derange the 
digestion, it would appear that the blood undergoes a change 
in the proportion of its constituents. 

Treatment. — The first step in the treatment of this disease 
is to change the diet. If it appear in a young infant, the quality 
of the milk may be suspected, and the nurse ought to be 
changed, or an artificial mode of nourishment substituted. 
Where it is attended with a febrile condition, or is evidently 
connected with irritating undigested substances in the bowels, 
some mild aperient may be given, as a little rhubarb and mag- 
nesia, or castor oil. In the same condition of the system which 
invariably attends the combination of urticaria and purpura, 
more active medicine may be required, especially where the 
liver is involved in the disease ; a full dose of calomel, followed 
by an aperient, will then be needed. When complicated with 
jaundice, the original affection will demand our principal 
attention. 

As the disease for the most part is attended with debility, 
and connected with impoverished food, a more stimulating and 
tonic course of diet will be needed, while the alvine evacuations 
are so ordered that one free motion is obtained in twenty-four 
hours. When there is absence of fever, the aperient may be 
slightly tonic and alterative, such as rhubarb, combined with 
aromatic powder, f If great debility exist, sulphate of quinine, 
or the infusion of cascarilla and Colombo, will be found far better 

* Dublin Medical Journal, vol. iii. 
t fy Pulveris Rhei, gr. xv. 
Hydr. c. creta, gr. vi. 
Pulv. Aromatic, gr. iv. M. 
Divid. in Pulv., No. vi. 
One three times a day, to a child three years of age. 



EXCERNENT SYSTEM. 383 

than the nitric acid, or any of the mineral acids so frequently 
resorted to in this affection, which greatly disorder the stomach 
and bowels of young children. The local application to bleed- 
ing parts should be of an astringent nature, and a solution of 
alum offers the best that can be used for arresting the hemor- 
rhage. In the latter stages of the disease, blood is often con- 
stantly oozing from the gums. Dendy recommends turpentine, 
as in the following prescription, for this and similar affections, in 
other parts of the mucous epithelium.* 

FURUNCULUS. 

Boils are not common in infancy, but are often seen during 
the period of youth in such as are of a plethoric or robust habit 
of body. They also occur from some irritation of the skin, 
arising from external causes, such as the use of irritating oint- 
ment, or the application of a blister, the irritation also of exten- 
sive cutaneous inflammation, as small-pox. It is not unusual 
for them to arise on the disappearance of other diseases ; and 
as they are occasionally connected with a slight derangement 
of the digestive organs, they probably owe their existence at 
this time to an over-excited state of the digestive mucous mem- 
brane attendant on the increase of its functions during conva- 
lescence. 

A boil or furuncle is an inflammatory tumour, of a circum- 
scribed and conical form, hard, red, hot and painful. It occupies 
the skin and cellular substance, and is seated in the conical 
prolongations of the sub-cutaneous cellular tissue, which pro- 
ceed from the inner surface of the skin to the external, where 
they form the papillae and vascular rete, with the vessels and 
nerves which accompany them. 

The symptoms are at first such as have already been men- 
tioned above ; and the hard nature and bright red colour of the 
tumour, are evident on its first appearance, even when its size 
is no greater than that of a small pimple. It is attended with 
violent pain, like that produced by the introduction of a large 
needle through the skin. In about a week the apex changes 
to a white colour, and breaks, discharging a small quantity of 
bloody purulent matter. A slough is seen arising from the 
bottom of the cavity, which is known by the name of the core ; 
while this remains, the boil will never heal. This slough is 

* R- 01. Terebinth., 3ss. 

01. Ricini, 3iij. 

Pulv. Acacise, 3iij. 

Aquee Anethis. M. 
ft. Haust. 
For a child of ten years of age, 



384 DISEASES OF CHILDREN. 

usually discharged about the tenth day, when the boil gradually 
heals. Boils are rarely attended with fever, unless they are 
very numerous. 

Treatment. — It was formerly the custom to attempt the 
removal of boils by the application of caustic, but this method 
is rarely successful ; and the most efficient way of managing 
them is to promote their softening, and bring them to an early 
termination by means of emollient fomentations and poultices, 
which may be mixed with an infusion of the extract of poppy 
in hot water, when there is much pain. Poulticing is the only 
effectual method of curing boils; for when once formed, they 
will always pass through their natural stages, and this process 
may be hastened by the constant application of warmth and 
moisture. When they are slow in breaking, they may be 
opened with a lancet. When boils are numerous, and return 
frequently, attention to the primse vise is indispensable ; and 
brisk purgatives, and where the tongue is much loaded, an 
emetic, will be needed to remove the accumulations which are 
invariably present under such circumstances. 

PSORIASIS. 

Psoriasis is a disease which was first described under this 
name by Dr. Willan, and arises from a disordered action of 
the vessels secreting the cuticle. It is a rough and scaly con- 
dition of the cuticle. These scales multiply rapidly, and have 
an irregularly circumscribed surface, and run into each 
other. They appear on all parts of the body, but more par- 
ticularly on the face, trunk and head. Through the cracks which 
sometimes appear in those scales, the reticular tissue may be 
seen of a red tint. 

This disease, in its various forms, may attack children at all 
ages, without any difference in the appearance from that ex- 
hibited by adults. Psoriasis guttata is the common form, and 
known by the appearance at first of small hard elevations, whose 
summits are covered with white scales ; these are diffused with 
interstices of different extent. When they assume a spiral form, 
they are denominated Psoriasis gyrata, and diffusa, when they 
increase, spread, and mingle together. One variety, which re- 
sembles the bark of a tree covered with lichens, has received 
the specific name of agria, and is the same as that described by 
Alibert, under the title of dartre squameuse lichenoides 

The disease, when it appears in new-born infants, has re- 
ceived the name of infantilis, from Willan. On this account, 
and from its extreme obstinacy, it has been regarded as a syphi- 
litic eruption. It appears in children from the time of birth 



EXCERNENT SYSTEM. ' 385 

to the age of two or three years, and is for the most part 
found among the poor, where bad diet and uncleanliness are 
combined. 

Treatment. — The treatment should be commenced with a 
close attention to the diet of the child, which ought to be 
nourishing and suited to its age. A free exposure to the fresh 
air, also, should form a part of the hygienic treatment ; while 
the warm bath must be daily in use until the irritation of the 
skin is relieved and the scales removed. These, in general, 
will be all the treatment needed ; but if there appear to be 
much derangement in the secretions of the chylopoetic viscera, 
small doses of hydrargyrum c. creta should be employed, to 
promote a more active secretion from the various organs of the 
digestive system. This is far better than to resort to active 
purgation ; for, in general, a change of diet or nurse, and a par- 
ticular attention to cleanliness, are all that is needed. 

PORRIGO FAVOSA. 

This is a pustular disease, occurring in different parts of the 
body, and distinguished, as its name imports, from affections 
strictly of the scalp, as it denotes the occupation of other parts 
of the body by the disease. The pustules are small in size, 
flattened at the top, and when the oozing concretes, form scabs 
resembling the honey-comb. When it occurs in the scalp, it 
is denominated tinea favosa, and then partakes of all the local 
peculiarities of cutaneous affections of this part. The pustules 
are large, soft, and slightly inflamed at the base, and consist of 
favi or achores, occupying the head, trunk and extremities. 

An attention to the general health of the patient is the first 
step in the management of this disease. Depletions and altera- 
tives will be needed at the commencement, although a general 
tonic course has often been found necessary. The latter plan, 
in long continued cases, will become the proper method of 
managing it, or where, perhaps, at the beginning of the disease, 
no other course could rationally be adopted than a gently de- 
pleting one. Mr. Plumbe states, that he saw a number of 
cases in a family of distinction, the children of which had long 
been suffering from that disease, which manifested no disposi- 
tion to improve, till a decided tonic plan of treatment was had 
recourse to. 

Soothing applications, of an emollient or sedative nature, 
will be necessary to relieve the pain and excessive irritation 
existing in the diseased part. But in the scalp it will often be 
impossible to derive any benefit from these or any other appli- 
cation, unless the accumulation of scabs is removed. This 

49 



386 ' DISEASES OF CHILDREN. 

should be effectually done by soaking them well with soap 
and water, and afterwards removing the hair with a razor. 
Fomentations and poultices will be necessary after these pre- 
liminary steps are taken, if the parts beneath are found inflamed ; 
when ordinary attentions to the general health will effectually 
remove every remnant of the disease. 

Should the vessels continue for a long time to pour out their 
morbid secretions, a relaxed state of the cutaneous vessels may 
be reasonably suspected, which it will be necessary to relieve 
by stimulating applications, such as a solution of nitrate of sil- 
ver, or of sulphate of copper. 

TINEA. 

Under the generic name of tinea will be included all the 
varieties of the disease, known as the different affections of the 
scalp. The term tinea appears to be more suitable to this 
affection than porrigo, as the latter applies to other affections 
also, and the term signifies a spreading abroad of the disease ; 
while tinea, from the import of the word — the destruction of 
the hair like that produced by moth — more clearly points out 
a disease of the hairy scalp. The various affections of this part, 
therefore, known under the different names of porrigo, teigne, 
scalled-head, ring- worm of the scalp, will be considered under 
the above title in as concise a manner as possible. 

There is no class of diseases in which so great a confusion 
of names exists ; rendering it almost impossible to identify those 
described by the French with the descriptions given by Eng- 
lish authors, or to ascertain from the appearance of the disease 
to which class or genus it belongs. Several species have been 
made of tinea and porrigo, according to the different appear- 
ances the disease presents ; some evidently, but a different stage 
of the disease, altering its appearance, also, from the changes and 
accumulations of the secretions. On this account, and also for 
the purpose of endeavouring to render the treatment more the 
result of principles derived from the pathological condition, than 
to rely entirely on a course nearly altogether empirical, which 
has been that for the most part adopted in the management 
of these diseases, the various distinctions will be discarded, 
agreeably to the recommendation of Mr. Plumbe, who thinks 
that the varieties have been multiplied to the great confusion 
and discouragement of the student. 

Tinea, in all its forms, appears to be far more prevalent in 
Europe than in the United States. Although often seen, yet it 
is comparatively mild, and does not so uniformly present the 
disgusting characters described by French writers. It is at 
times a very severe and obstinate affection, and isolated cases, 



EXCERNENT SYSTEM. 387 

bearing all the appearances described by those who take their 
descriptions from the instances occurring in Continental Europe, 
do occasionally occur. 

Etiology and Pathology. — These are very obscure. All 
that is known respecting them is, that tinea appears to originate 
in the application of infectious matter from others affected with 
it. It has, however, appeared without any such cause ; and as 
it is evidently local, it appears to arise from some alteration 
in the action of the capillary vessels of the part. It sometimes 
is hereditary ; and the predisposition unquestionably exists in 
a deranged digestion. It is at times produced by blows and 
wounds on the scalp, or by the slightest excoriation. 

The seat of tinea appears to be in the reticular tissue of the 
scalp, but the disease has been found involving the whole of 
the layers of the scalp, even to the bone. On this account, its 
seat has by some been fixed in the bulbs of the hair, these being 
situated beneath the reticular tissue. This is in all proba- 
bility the case, as the falling off of the hair is a most remark- 
able symptom. The blood-vessels secreting the hair, may, 
from extreme excitement, prevent the part secreting the hair 
from its reception of a proper supply of nourishment. Mr. 
Plumbe thinks, that in the form of the disease which assumes 
the distinctly pustular appearance, the presence of the hair be- 
comes an irritating cause, when inflammation already exists in 
the cutis; for each pustule contains a hair which acts as a 
foreign body. 

Semeiology. — The general symptoms of tinea are, at first, 
itching, and the appearance of variously sized tumours of differ- 
ent shapes, either pisiform or conical, with ulceration of the 
scalp. These are followed by the oozing of a purulent fluid, 
and the formation of scabs of a yellow or whitish colour. 
Sometimes they are of a definite shape, matted with the hair ; 
at other times they are large, and cover the whole head like a 
cap, adhering very closely, and again, they fall off in small 
pieces, like bran. From these and other circumstances a number 
of varieties has been formed ; but as the different appearances 
are rather the result of some accidental circumstances, than 
any difference in the action of the vessels causing the disease, 
the number may very advantageously be reduced, and, as sug- 
gested by the author above mentioned, the characters taken 
rather from the actual condition of the diseased part, before 
any alteration has occurred in the secretion. From this there 
appears to be actually but two original forms of the affection ; 
the others arising from several circumstances occurring during 
the course of the disease, and materially altering the appearance 
of the secretions. One distinct form is the common ring- worm 



288 DISEASES OP CHILDREN* 

of the scalp, and the other is the pustular variety. These, and 
especially the latter, assume all the appearances which tinea 
presents during its progress. All these may, from the extension 
of the disease, and the involving of the different tissues, and the 
accumulation of the abundant secretions, become very varied 
in their appearance, and obstinate and unyielding under any 
course of treatment that may be adopted. 

The most common form of tinea is the circumscribed form 
known as the ring- worm of the scalp. The first intimation of 
its existence is the falling off of the hair, as if destroyed by 
some insect, which* indeed, it was formerly supposed was the 
case. The spots have a circular form, of a greater or less 
regularity, generally scurfy along the margin, at other times 
exhibiting the appearance of minute vesicles or pustules. At 
this stage of the disease there does not appear to be any secre- 
tion from the diseased part ; but when any puriform matter 
oozes from it, small scabs of a straw colour form, which, on 
being removed, leave the surface beneath considerably exco- 
riated. This latter form exists where the cutis possesses natu- 
rally an exalted state of irritability, but the disease in fact is 
the same. These patches exist in different parts of the scalp 
at the same time, but different in size and stage. Some in 
their incipient state, having the appearance of a small yellow 
coloured spot, and others in various sized circles, generally 
bordered with small achores. When the pustules form, there 
is a considerable itching, when the disease spreads with great 
activity, while the drying of the fluid of the pustules produces 
scabs over every part ; these scabs become, from their hard 
and intractable nature, new sources of irritation, when more 
extended inflammation of the scalp follows, and purulent secre- 
tion, from a more extended source, obscures the original form 
of the disease. 

Treatment. — -The principle which should be adopted in 
this form of disease, and such as experience has sanctioned, is 
either the establishment of an entire new action in the capillary 
vessels by the application of powerful stimulants, or the de- 
struction of the capillary vessels themselves, on the disordered 
action of which the disease depends. These are the yellow 
wash, solution of the nitrate of silver,* sulphate of copper,f or 
any of the mineral acids, which may be used in an undiluted state. 
The latter is the best, for nothing can be relied on that will not at 
once cause an alteration in the action of the part ; a destruction 



fy Argenti Nitrat., gr. xv. 
Aquse Destill., gj. M. 



t fy, Cupri. Sulphatis. gr. v. 
Solve in 
Aq. Destil., fv. M. 



EXCERNENT SYSTEM. 389 

of the part follows the application of these powerfully corrosive 
applications, and after the separation of the eschar, some slight 
suppuration follows. The whole of the hair on the diseased 
part should be removed, and the acid applied for a few minutes ; 
it should then be carefully washed with soap and water. 
Either of the mineral acids maybe used, but the sulphuric and 
nitric appear to be the most efficacious. This is generally all 
that is required to remove this form of tinea. 

Tinea Favosa. — This is a more diffused and distinct form of 
the eruption, consisting of small pustules, occurring in patches 
on different parts of the scalp, attended from the beginning with 
great itching. The drying of the purulent oozing forms scabs, 
which are strongly attached to the skin, with a depression in the 
centre, and has led it to be compared to the lupine seed, formerly 
used both as food and for emollient applications. The extension 
of this form is much more rapid than the former, and pustules 
arise in every part, attended with secretion of a large quantity 
of purulent matter, which, matting the hair and drying, forms 
extensive scabs. When these are removed by means of warm 
water, an erythematous inflammation appears on the cutis, 
while it is entirely denuded of its cuticle. A variety of acci- 
dental circumstances arise to give the disease a difference of 
appearance, and the term scalled-head has been applied to that 
state in which the head is covered with accumulated secretions. 

The rapid formation of pustules, Mr. Plumbe thinks, may be 
traced to the influence of the hair on the part; for where the 
hair has entirely disappeared, the disease does not exist — 
the irritation of the hair causing the inflammation, for every 
pustule will, on examination, be found to contain a hair. The 
inflamed skin is thus kept in a state of constant irritation by 
the growing hair. 

Treatment. — Mr. Plumbe's method of treating the pustular 
variety differs very materially from the method recommended 
for the preceding form. The first attention, he observes, must 
be paid to the general health, and such local measures as are 
the best adapted to subdue irritation, and preserve the parts 
clean ; and by the early removal of the contents of the ruptured 
pustules, prevent the matting of the hair, and the additional 
irritation from the hardened condition of the dried scabs. 

It is rarely necessary to have recourse to much active mea- 
sures of a constitutional nature. It is only where the affection is 
evidently aggravated by some existing derangement of the sys- 
tem, usually of the digestive organs, or by the peculiar irritability 
of the skin, arising in scrofulous habits, that these are called for, 
or where the constant local irritation excites febrile action. 

The first step in the local management is to remove the en- 



390 



DISEASES OF CHILDREN. 



crusted secretions with soap and warm water, and then to 
pluck out the hairs on every portion of the affected part by 
means of a forceps, which is very easily done. The hair over 
every part of the scalp ought to be cut off with a fine 
scissors, if the disease be extensive. The pus should be daily 
removed by ablution with soap and water, and stimulating ap- 
plications made to the pustules. A solution of sulphate of cop- 
per answers this purpose the best of any. This process should 
be daily observed until the diseased action is altered. The 
pustules will gradually cease to be formed, while the cutis has 
a red and shining appearance, and soon becomes covered with 
fine new hair. 

The disease is sometimes of remarkable obstinacy, spreading 
and forming extensive scabs in some parts, while others are 
affected with successive formations of pustules. It is to this 
form of the disease that the term scalled-head is applied ; and an 
almost infinite variety of applications has been recommended, 
some of a stimulating, and others of a sedative nature. One 
of the best is the unguentum hydrargyri nitrati diluted with 
an equal quantity of ceratum simplex, for young children. The 
ointment, also, of sulphuric acid is a highly useful application. 
Both of these quickly allay the itching, and thus remove a great 
source of irritation. Ointment of capsicum, mustard, and of 
other stimulating vegetables, have been successful in some obsti- 
nate cases. The annexed formula, also, has been found emi- 
nently useful in long and obstinate instances.* Tar oint- 
ment, either alone or combined with sulphur, has been a 
favourite popular remedy, and appears to have succeeded 
when other means have failed. Lotions of sulphate of zinc, 
sulphuret of potash, the water obtained from the preparation of 
carburetted hydrogen, have all been useful in such cases. 

Among the remedies which have been used with success is the 
chloride of lime, in the form of a liniment. The subjoined for- 
mula is used by Trusen ;f or it may be employed in the more 
simple one here annexed. J 

The iodide of sulphur, prepared by mixing sixteen grains of 
sulphur with two drachms of iodine, and slowly heating it over 
a gentle fire until they are completely fused into one mass, 



* fy Plumbi Carb., §j. 
Pulv. Litharg., 3ij. 
Hydr. Deut. Chlorid., 3iss. 
Axung., §iv. 
Terebinth. Venet., fj. M. 



t fy Calcis Chlorid., 3ss. 
Aq. Rosae, §j. 
01. Amygd. Dulc, §j. M. 
The first two ingredients to be rubbed 
together in a mortar, being gradually 
mixed, and when clear, the last to be 
added. Applied by means of a pencil. 
t ~fy Aquse Chlorin., 3j. 
Olei Olivar., ly M. 



EXCERNENT SYSTEM. 391 

when made into an ointment, in the proportion often grains to an 
ounce of lard, has been highly recommended as succeeding in 
some very obstinate cases.* The ointment to be rubbed on 
night and morning, gradually increasing its strength to a drachm 
to the ounce. 

It is sometimes necessary, where great irritability is com- 
bined with extensive inflammation, to employ some anodyne 
applications. Coculus indicus, made into an ointment, in the 
proportion of two drachms to an ounce of simple cerate, has 
been used where these remedies are indicated. A poultice of 
cicuta is also highly beneficial under such circumstances, as 
is also a decoction of poppy-heads. 

In very old cases, with a great accumulation of desiccated 
purulent matter, Mr. Plumbe found pressure with adhesive 
straps, and the application of lead water, a very efficient remedy. 

FROM CONSTITUTIONAL DEBILITY. 
ECTHYMA-PAPULOUS SCALL. 

This disease consists of large pustules, rising from a hard 
bright red base, and covered with a greenish yellow scab. 
These pustules may arise in any part of the body, but are rarely 
seen on the scalp, although not confined to any particular part ; 
yet, when once developed, they are limited to one region. 
When the pustules are fully formed they bear a great resem- 
blance to small boils. When there is but one eruption de- 
veloped, it runs its course in a very short time : in other cases 
it is continually renewed, multiplies, and becomes confluent. 
From these circumstances have arisen the divisions of authors, 
and particularly that of acute and chronic. There is one 
species which, from its occurring in infants that are debilita- 
ted from bad food, or who have recently recovered from other 
diseases affecting the skin, such as small-pox, has received the 
name of ecthyma infantile. It is also connected with a chronic 
affection of the digestive apparatus, and is always attended with 
Jassitude, debility, and great emaciation. Besides the cause 
already mentioned, the cold and damp of the spring of the year, 
close and confined habitations, and filthy clothing, frequently 
develope the disease both in adults and children. 

Treatment. — This should mainly consist of hygienic mea- 
sures; and when the disease is observed to occur in infants at 
the breast, immediate attention should be directed to the con- 
dition of the nurse's milk. A change in the nurse is often all 
that is necessary in effecting such a change in the constitution 
of the child as will insure a recovery. 

* Lond. Med. Gazette, Sept. 1837. 



392 DISEASES OF CHILDREN. 



PEMPHIGUS. 



This affection is known by the existence of an eruption of 
large yellowish and transparent bullae. This first appears in 
the form of circular or oval spots, slightly raised from the 
surface, at first of a red, and afterwards of a dusky hue. A 
quantity of serum is poured out beneath the cuticle, which 
raises it in blisters or blebs. Several varieties of this disease 
have been made, from their mode of appearance, the rapidity 
of their course, or from the absence or presence of febrile 
action. The age of the patient, also, imparts some peculiarity 
in its form, from which a species which is called congenitus, 
or infantilis, has been made. 

It may be either acute or chronic ; the former is not uncom- 
mon during dentition, but then there is not much fever accom- 
panying it. The latter is attended with great emaciation ; and 
little or no hope can be entertained of recovery, as it occurs in 
connection with other affections, and is to be regarded rather 
in the light of an unfavourable symptom than as a distinct 
disease. Still, benefit may be derived from the application of 
stimulating ointments, such as the urguentum acidi nitrosi, 
where the skin is continually covered with new scabs. 

In both forms it will be necessary to pay the closest attention 
to the quality of the milk, and to change the nurse ; and where 
the child is artificially nourished, it will be of the greatest 
importance to procure milk of a good quality, for more will 
depend on this than on any therapeutic measures that can be 
devised. 

When the serum has been discharged from the blebs, either 
naturally or artificially, which may be done when they are 
large, the part ought to be carefully guarded from friction by 
means of lint spread with simple cerate. Willan and Bateman 
both advise, in addition to a tonic regimen, the application of 
cinchona, in the form of a lotion, to the skin, and hot baths. 
Pinel, on the contrary, recommends that all topical applications 
be withheld, as the disease is but a symptom of other affections. 

RUPIA. 

Rupia is characterized by an eruption of broad flattish dis- 
tinct vesicles or bullse, filled with a serous fluid, which becomes 
opaque and puriform. Scabs are continually formed, of a brown 
or black colour, with ulcers beneath them, which are seen when 
the scabs, which are easily rubbed off, are removed. These 
ulcers, if left to themselves, either heal or are covered with 
other scabs: this process often occurs several times in succes- 
sion. When the ulcers are finally healed, the skin remains for 



EXCERNENT SYSTEM. 393 

a long time deep red or livid. Rupia appears on the legs and 
thighs, and sometimes on the loins, but rarely on any other part 
of the body. 

Children of a scrofulous habit of body, and those of a delicate 
constitution, and the offspring of impoverished parents, are 
those most liable to the atonic and obstinate ulcers forming the 
disease under consideration. Rupia escharotica, according 
to Bateman, is the species which most commonly occurs in in- 
fants at the breast, who are badly nourished, and who suffer from 
protracted sickness. 

Treatment. — The first object is to improve the general 
strength of the child by a suitable nourishment, and the free ex- 
posure to fresh air. A good nourishing diet, of which animal 
food forms the principal ingredient, will be required for children 
that are advanced in age, and a change of nurse for those that 
are at the breast. In short, all that has already been recom- 
mended under the head of scrofula, will be needed for children 
suffering from this or kindred complaints. 

The local treatment ought, in the first instance, to consist of 
emollients, applied with a soft rag or piece of lint. When the 
scabs are separated, and the ulcers appear to be of an indolent 
nature, some stimulating wash will be needed to excite a proper 
action in the capillaries of the part, for the formation of a new 
epidermis ; a weak mixture of brandy and water will be found 
useful for this purpose. Cream of tartar has been used by M. 
Rayer, by dusting it over the part, and he considers it the best 
application he has used for the ulcers of rupia. The sulphurous 
baths have also been used in obstinate cases with much benefit ; 
and where the disease is extensive, the common warm bath is 
indispensable to cleanse the body from the accumulation of 
scabs, and to excite a salutary action in the cutaneous vessels. 

FROM SPECIFIC CONTAGION. 
SCARLATINA. 

By some it is believed that scarlet fever is a disease of mo- 
dern origin, and that it dates its existence comparatively but a 
short time back. By others it has been thought that a descrip- 
tion of it is to be found in the works of the ancient Greek and 
Roman writers on medicine. The accounts, however, which 
they give of diseases that have been supposed to describe scarlet 
fever, are entirely too vague to be relied on for the establish- 
ment of the fact of its existence at that early period ; yet it 
can scarcely be supposed that it did not exist, but the probability 
is, that this affection was confounded with other diseases which 
bear to it some resemblance. 

50 



394 DISEASES OF CHILDREN. 

According to Rayer, Ingrassius was the first who described 
it with accuracy, in the year 1556, as it existed in Naples in 
1550, where it was known under the name of rosalia. It 
also prevailed in Paris in 1581, and an account of this epidemic 
is given by Ballonius.* From this time a vast number of trea- 
tises has been written on this subject in every part of the world, 
of which it would be almost in vain to attempt the enumeration. 

Notwithstanding the accounts we have in the earlier essays, 
the identity of the disease with scarlatina of the present day 
has been doubted ; and even the disease so accurately detailed 
by Sydenham, which prevailed between the years 1600 and 
1670, would appear to be a different affection from that more 
recently described under the same name by Morton, Cotton, 
and others. The extreme mildness of the symptoms charac- 
terized the disease at this period, and would thus render it diffi- 
cult to identify it with that which, with similar symptoms in 
general, is at times one of the most formidable and fatal diseases 
of childhood we have to encounter. 

Besides the epidemics above mentioned, which are the ear- 
liest accounts of its appearance in Europe, we find records of 
its ravages, for the first time in North America, in 1735, when 
it spread extensively over New-England and the Middle States. 
It again raged as an epidemic in the year 1784, and spread 
over the greater portions of the Northern States. From that 
period to the present it has continued to prevail over the conti- 
nent, varying in intensity in different places, and possessing in 
each peculiarities in the symptoms, which make the experience 
acquired in its treatment in one epidemic often inapplicable in 
another. 

It attacks all ages ; but so rarely is it found to affect adults, 
that it may be regarded as a disease peculiar to children. 
Among them, although often a mild disease, yet frequently it is 
marked by the violence of its invasion, its intractable nature, 
and its suddenly fatal termination ; and where the epidemic 
prevails, the introduction of the disease into a family is re- 
garded with dismay, almost without parallel among the pecu- 
liar affections of childhood. It becomes, therefore, one of the 
most interesting diseases to the physician, and one which still 
needs much investigation as to the nature of its causes, and 
the morbid changes which they produce in the system, and 
which so often defy the most powerful efforts for their re- 
moval. 

Etiology. — The exciting cause of scarlet fever is a specific 
miasm or contagion, but with the origin of which we are 

* Rayer, p. 183. 



EXCERNENT SYSTEM. 395 

unacquainted, and probably shall never know whether it is 
generated within us, or arises from some combinations of the 
constituents of the atmosphere, whereby it acquires the pro- 
perties of exciting the morbid actions constituting the disease. 
It would seem at times to appear sporadically, and to depend 
on local circumstances, which will give rise to a fever pos- 
sessing a scarlet eruption, under circumstances of simple expo- 
sure, similar to those which produce ordinary inflammatory 
fevers. 

However originally generated, the disease is unquestionably 
contagious, being communicable by virus formed in the body. 
This seems now to be almost generally admitted, and numerous 
examples exist in the different professional records in illustra- 
tion of this fact. Instances of its having been communicated 
from one individual to another I have frequently known ; in 
one of which, four adult females, who successively had the im- 
mediate charge of a child that died from the disease in its 
most violent form, were within four days attacked with inflam- 
mation and ulceration of the throat, having all the character- 
istics of the inflammation of the anginose scarlet fever. These 
persons alone attended to the child, frequently holding it on the 
lap ; no others in the house were affected with the disease in 
any form. 

There are various circumstances, both of the atmosphere 
and of the individual, which influence and control the action 
of the contagious principle ; and hence a great diversity occurs 
in the disease in its epidemic character, and also, as it affects 
patients, from their different conditions of system. 

It prevails mostly in winter, when the weather is changeable, 
damp and cloudy ; and it has been observed to occur with as 
much frequency about the period of the equinoxes, at which 
time the atmosphere is usually in the same condition. As a 
general rule the disease appears to be less virulent where the 
atmosphere is pure ; and, consequently, is more violent and 
fatal among the poor, whose crowded and ill-ventilated habi- 
tations afford a proper nidus for its developement and exten- 
sion. There are not wanting examples where two and three 
children of those enjoying all the comforts that wealth can 
give, are simultaneously attacked, and die with the disease in 
its most malignant form. The nature of the atmospheric 
changes modifying the severity of scarlet fever, as in other dis- 
eases, is unknown ; but that it is more virulent and active than 
most others, is evident from the fact just stated ; and although, 
like the morbific causes of disease in general, the miasma is 
more severe in its effects in an impure air, yet we see that the 
advantages of free air and well-ventilated apartments are not 



$96 DISEASES OF CHILDREN. 

sufficient to protect the inmates from the deadly influence of 
the contagion of scarlet fever. For the same reason that the 
disease prevails more at those seasons when the atmosphere is 
loaded with moisture, is it found to exist more along the course 
of rivers, and in the neighbourhood of lakes and ponds, the 
dampness confining the miasma to the spot, where it becomes 
more concentrated and virulent. The peculiar effects, also, of 
a cold and humid air, doubtless has its influence in predisposing 
the body to disease, by arresting the healthy organic action of 
the cutaneous system, and causing a corresponding disturbance 
in other tissues and organs ; the healthy equilibrium being once 
destroyed, the existing epidemic cause of disease has thus an 
opportunity of exerting its peculiar influence. 

All are not equally under the influence of scarlatina; many 
escape, when exposed to the disease in its most aggravated 
form. It is said to attack females more than males,* but this 
is a fact much to be questioned ; for if such be in reality the case, 
it must be more fatal to males than females, for of 158 fatal cases, 
which occurred in the year 1839, in the city of New-York, 86 
were males, and 72 females. f Of 391 deaths in 1840, 208 were 
males. 

Although children, at all ages, are liable to be attacked w T ith 
the disease, yet infants at the breast are not so often affected 
with it as older children. This has been observed in the hos- 
pitals in Europe which are devoted exclusively to children at 
different periods of life. It is difficult accurately to arrive at 
the precise fact in this country from public statistics ; but if the 
annual reports of deaths be any criterion, such would appear 
to be the case. In the epidemic which prevailed in the city of 
New-York, in 1837, out of 579 deaths, 72 were children under 
one year, 125 between one and two. 

In 1839, the deaths from scarlet fever amounted to 158. Of 
this number 17 were under the age of one year; 25 were be- 
tween one and two ; 79 between two and five, and 28 between 
five and ten. In 1840, 334 deaths occurred among children 
between one and ten years, out of 391. During the period of 
twenty years, from 1807 to 1827, the deaths from this disease in 
the city of Philadelphia, amounted to 102. Of these, eight were 
under the age of one year ; 1 1 between one and two ; 37 between 
two and five, and 17 between five and ten. J It would appear, 
therefore, to prevail less frequently among sucking infants, which 



* Rayer, Op. Cit., p. 173. 

t Annual Report of Interments, etc., by William A. Walters, City Inspector. 
t Emerson's Medical Statistics, Amer. Journal of the Med. Sciences, vol. i. for 
1827. 



EXCERNENT SYSTEM. 897 

has also been remarked by Billard, and by American physicians. 
Children of the age of three to five years are more often the sub- 
jects of this affection than others. Boarding schools, and the 
hospitals devoted to the reception of children of all ages, often 
have the disease prevailing as an epidemic, while in the found- 
ling hospitals, which contain children only of a very tender 
age, it is scarcely ever seen. 

Children of a sanguine temperament and robust habit of 
body are those most liable to be attacked, and in them the inva- 
sion is often very sudden, and quickly fatal. The most violent 
forms of the disease which I have seen, have occurred in chil- 
dren, who, at the time of their seizure, were in the enjoyment 
of the most vigorous health, terminating fatally in from twelve 
to thirty-six hours. 

Semeiology. — The usual divisions of scarlet fever are taken 
from the appearances which the disease exhibits, and are re- 
garded the best, both for accurate descriptions and for the gene- 
ral direction of the treatment of the disease in all its forms. 
The first of these is, where the rash alone exists without any 
concomitant affection, denominated scarlatina simplex; the 
second, where inflammation of the fauces attends the eruption, 
and known as scarlatina anginosa; and third, where the latter 
affection is attended with ulceration, sloughing and typhoid 
symptoms, and distinguished by the title of scarlatina maligna. 
These different species are described as uniformly existing as 
such, and consequently easily recognised ; but this is not 
always the case, for during the prevalence of an epidemic, not 
only are all these forms found simultaneously and in different 
degrees of virulence, but the mildest often passes into the 
severer, and that which at first was but a slight affection, and 
to appearance devoid of danger, may almost imperceptibly 
become inflammatory with the tonsils and glands, which at 
the commencement exhibited but the slightest blush, swelling 
to a great size, and gradually exhibiting extensive ulceration 
and sloughing, and terminating in the death of the patient, with 
all the symptoms attending scarlatina maligna. The malignant 
form, to which the ulceration and sloughing of the throat are 
an essential part, rarely attacks the patient at the immediate 
onset of the disease, but is the effect of previous inflammation, 
varying in its duration, which is often very short. 

The disease, in fact, from the lightest to the most serious 
form, is but one, differing in different cases only according to 
the violence of the invasion, the extent and number of tissues 
affected, and the modification it undergoes from the immediate 
influence of the exciting cause acting with more or less viru- 
lence, and also from the previous condition of the individual 
attacked. However convenient these divisions may be for 



398 DISEASES OP CHILDREN. 

nosological description, it is of more importance to consider it 
as one disease, liable even in its mildest form to extend to 
different tissues, and to alter in its character during its progress. 
The disease, when so regarded, will be more attentively 
watched ; and the violent symptoms, which are at times remarka- 
bly gradual in their advance, be much more likely to receive 
that prompt attention which alone can control this formidable 
affection. 

This naturally leads to the consideration of the different 
modes of attack, and the actual progress of the disease, for a 
division of symptoms taken from these circumstances has a 
direct bearing on the treatment; and the practitioner should be 
always prepared not only to combat it in its peculiar form at 
first, but also to be ready to enceunter the most severe symp- 
toms which may arise, even after the invasion of the disease 
in its mildest form. 

Scarlet fever, as it has appeared in our late epidemics, has 
uniformly assumed at its commencement one of three prom- 
inent forms : that of inflammation more or less violent, of con- 
gestion of the brain, and congestion of the pulmonary system 
and heart. Scarlatina simplex, or the cutaneous disease alone, 
without any inflammation of fauces, I have never seen ; but 
there has always been some degree of inflammation of this part, 
often, indeed, very slight, accompanying the cutaneous eruption. 
As the scarlatina simplex, the disease without anginose affection, 
has been described by Sydenham, Cullen, Frank, Gardien, and 
others, it has unquestionably existed, and therefore forms a ne- 
cessary part of the account of the disease, which will be de- 
scribed as commencing under four different forms. First, the 
simple. Second, the inflammatory — the inflammation existing 
not only in the congeries of mucous follicles of the throat, form- 
ing the tonsils, but also occupying the trachea, bronchiae, gas- 
tric mucous membrane, and even the cellular tissue. Third, 
the cerebral congestive form, known by the extreme sudden- 
ness of the attack, the loss of almost all muscular power, and 
the paleness of the surface. Fourth, the pulmonary and cardiac 
congestion, where a similar loss of muscular power exists, 
but accompanied with a deep modena hue of the skin, occasion- 
ally mottled with purple spots. These are the forms under 
which the disease appears at first, but, as may be supposed, 
not in every instance so uniform and distinct as to be uncon- 
nected with the other. The congestion may not always be 
complete, or unaccompanied with symptoms of inflammation, 
and the congestion of one part being often quickly followed by 
another : that of the lungs almost always being succeeded by 
that of the brain. These, however, are sufficiently distinct for 
a practical description of the disease. The simplest appear- 



EXCERNENT SYSTEM. 399 

ance of scarlet fever necessarily comes first under our notice, 
in which the most perfect form of the eruption appears ; it 
therefore becomes the proper type of the cutaneous affection : 
the more complicated and virulent being attended with some 
alteration in the morbid condition of the skin. 

In the ordinary scarlet fever, without complication, the first 
period is characterized by a feeling of debility, with chilli- 
ness, alternating with more or less heat. There is also 
headache, and sometimes nausea and vomiting. All these pre- 
cursory symptoms are increased towards night. Occasion- 
ally, however, the eruption takes place without any of these 
symptoms. 

The eruption usually appears on the second day of the 
attack, in the form of small spots, at first on the breast, neck 
and face ; these are of a pink colour, with the skin between 
them of the ordinary hue. These spots increase in number, 
and cover the rest of the body within twenty-four hours. At 
this period of the disease, I have never seen the tongue and 
fauces without their marks of the inflammation, although it has 
been described as destitute of any appearance of inflammatory 
action. The appearance of the eruption differs on the third 
day, when the interstices above mentioned change to patches 
of a light scarlet colour, irregular in their form. The efflo- 
rescence is not uniform over the body, but is more vivid in the 
articulations, and about the large folds of the skin. On the trunk 
the patches are much larger than on the limbs. A roughness, 
produced by the elevation of the cutaneous papillae, from the 
determination of blood to them, occurs on the outer parts of the 
arms and thighs. When at the height, the eruption is more 
vivid in the evening and at night than at any other part of the 
day ; it is then of a very bright scarlet, and has been compared 
to the colour of a boiled lobster, or the stain produced by the juice 
of the raspberry. 

On the fifth or sixth day the eruption changes its colour to a 
paler hue, when a desquamation of the cuticle commences, 
which is at its height on the eighth day. 

The tongue is sometimes furred white, with the sides red, at 
the commencement of the disease ; but becomes red, as above 
mentioned, on the appearance of the eruption. 

At the period of the disappearance of the eruption, it is not 
unusual for a new crop of scarlet spots to arise, of a small size, 
and fewer in number, which soon disappears, with a free per- 
spiration. 

Where the disease assumes an inflammatory form, the above 
symptoms are combined with a greater or less inflammation of 
other organs and tissues, besides the external covering of the 



400 DISEASES OF CHILDREN. 

body. This inflammation can indeed be seen, as I have before 
observed, in the fauces, even in the slightest degree of the 
cutaneous eruption, and exhibits in different cases all the 
phases of inflammation, from the slightest blush, to an enlarged 
and excessively painful condition of the tonsils and adjacent 
parts, and its ultimate consequences, the extensive ulceration 
and sloughing, so often occurring in the worst forms of this dis- 
ease. Scarlet fever may, therefore, be considered in all its 
forms as one disease, differing only in degree, in which the 
extension of the morbid changes in the different tissues may 
often be distinctly traced. There is the simplest form, in which 
scarcely any other morbid action can be discovered beyond 
those. already described; and in the same epidemic may also 
be seen, not only inflammation of the fauces, but also that of 
the different portions of the alimentary mucous membrane, of 
the membrane lining the trachea and bronchiae, of the cerebral 
meninges, and of the cellular tissue throughout the body. All 
these may exist, variously combined as to degree, in every 
severe case of inflammatory scarlet fever; but one or other 
will be the prominent aspect the disease assumes. The in- 
flammation affecting the fauces being the most common, and 
usually preceding the others, demands the first attention ; it 
being, however, borne in mind, that the inflammatory form of 
the invasion, where excess of vital action prevails, is here under 
consideration, let the seat be where it may ; in contradistinc- 
tion to the congestive form, where a loss of vital energy cha- 
racterizes the first symptoms of the disease, a difference of 
great importance in a practical point of view. 

This form is ushered in with the ordinary symptoms attend- 
ing inflammatory fever. At first there is a feeling of chilliness 
and weakness, with pain in the loins, which are quickly follow- 
ed by reaction, with the usual symptoms of quick and anxious 
respiration. The pulse is rapid, often hard and full ; and the 
surface of the body much hotter than in ordinary fevers, some- 
times rising even as high as 112° Fahrenheit. Generally there 
is severe pain in the head ; nausea and unquenchable thirst at- 
tend the violent invasion of the disease. These are the most 
strongly marked symptoms with which the disease commences, 
and usually precede the eruption two days. 

It is not, however, always that the citadel is thus violently 
invaded ; for often a most violent and inflammatory scarlatina 
will follow symptoms of remarkable mildness. After a slight 
degree of fever, succeeded by the usual morbid changes in the 
cutaneous surface, and when hopes begin to be entertained of 
the speedy recovery of the child, it is by no means an unusual 
thing to find the inflammation of the tonsils gradually, but 



EXCERNENT SYSTEM. 401 

steadily increasing ; the neck and face becoming enormously 
swollen, and the disease assuming, almost imperceptibly, cha- 
racters which give the worst prognosis, contrary to that 
which may have been entertained, from the mildness of existing 
symptoms. 

When the fever commences violently, the appearance of the 
rash is about the second or third day ; but in this, and in the 
parts in which it appears, there is not always a uniformity, for 
it does not always cover the whole body, but is mostly found 
on the inside of the thighs, and about the elbows and wrists. It 
will often appear and quickly disappear, and vary much in its 
intensity. This irregularity is always connected with severe 
constitutional symptoms. For the most part, the eruption is 
general over the body and members, while the skin is very hot 
and arid. 

If the febrile symptoms are not early abated, the fauces soon 
become much inflamed, commencing with a feeling of stiffness, 
and attended with a difficulty in deglutition. If this part be ex- 
amined, it will usually be found swelled, with patches or streaks 
of red occupying indiscriminately the tonsils, uvula, and poste- 
rior part of the pharynx. The inflammation increasing, the 
fauces exhibit a uniform redness, which increases and spreads 
with the continuance of the constitutional affection. The whole 
of the soft palate and tonsils present a tense and shining ap- 
pearance, with lines and patches of inspissated mucus or co- 
agulable lymph deposited on them, adhering closely to the part 
from which it is secreted ; it is the product of the deranged 
secretory functions of the inflamed glands. This exudation 
may be mistaken for the beginning of ulceration. 

Small vesicular elevations are at times formed on the in- 
flamed mucous surface ; these often unite and break, exhibiting 
in their place red excoriations, which, however, are soon, in 
favourable cases, covered with a new epidermis. If the inflam- 
mation continue violent, not only do the general symptoms in- 
crease in severity, but the character of the inflamed tonsils 
very materially alters. The colour becomes darker, and even 
livid, around the aphthous elevations above named. When 
these break, the parts beneath exhibit a dark, excoriated sur- 
face — a true sloughed or gangrenous condition. 

These changes are always attended with a corresponding 
increase of unfavourable symptoms in the circulatory system. 
The pulse is small, feeble and irregular, and the breathing short 
and oppressed. The heat of the surface is irregular, generally 
much less than when the circulation is in a comparative degree 
of normal activity. Its equilibrium is destroyed, and congestion 
takes place in the brain alternately, with short periods of 

51 



402 DISEASES OF CHILDREN. 

excitement; hence dulness and stupor alternate with great 
irritability, peevishness, and sometimes with violent delirium. 
The eyes are blood-shotten and suffused, and the cheeks are 
more than usually flushed. The mouth and teeth are covered 
with a brown sordes, and the breath is extremely offensive. 
Mucus, of a very viscid nature, is secreted about the throat 
and fauces, producing a difficult and noisy respiration ; and 
when secreted more freely from the surface of the trachea and 
bronchial tubes, which is commonly the case in young infants, 
suffocation is often threatened, from the almost complete clog- 
ing up of the air-passages. Sudden and violent coughing 
will at times remove the threatened danger, by filling the fauces 
and mouth with thick mucus from these passages, which is 
with difficulty completely removed by the fingers. 

These violent symptoms may appear at very indefinite 
periods, sometimes not until the second or third week, and at 
other times very shortly after the invasion of the disease. 
There is no difference in the aspect of the inflammation of the 
throat at the commencement, be its duration what it may. 
But when these unfavourable symptoms ensue early, great 
irregularity takes place, both in the appearance and duration 
of the eruption, which varies in colour and extent, being usually 
of a dark red or purple hue, and appearing and disappearing 
in different parts of the body ; and the constitutional symptoms, 
above detailed, exhibiting a more marked evidence of the serious 
loss of vital energy in the system. Some epidemics of scarlet 
fever have been characterized by the quickness with which 
the animal powers are prostrated, and the consequent rapidity 
of the ulceration and. sloughing of the inflamed parts, when a 
general collapse of the system soon shows itself. At other 
times, the same characteristic|symptoms will appear in some 
individuals who are exposed to those exciting causes which 
produce a mild disease in others, arising- from some inscrutable 
peculiarity of constitution. 

During the progress of the disease, the nares are often the 
seat of inflammation, which causes a secretion of thin sanious 
matter to be poured out in great abundance from the nostrils, 
of a highly acrid quality, adding greatly to the general distress 
from its excoriating the lips and cheeks. The gangrenous 
condition of the throat in scarlet fever differs in no respect 
from cynanche maligna, except in the presence of the eruption, 
which is its characteristic, in its more extensive complications, 
and in the greater tendency to congestion of important and 
vital organs. 

The gastric mucous membrane at times partakes of the in- 
flammation to a greater degree than other membranes, when 



EXCERNENT SYSTEM. 403 

the same viscid secretion takes place in the stomach. Under 
these circumstances it is often surprising what enormous doses 
of medicine are required to produce any effect ; and when this 
organ is lined with the thick and tenacious mucus from these 
inflamed membranes, it is almost impossible to obtain any 
operation from the administration of emetic substances. This 
is generally present during the active stage of the scarlet 
fever ; but, when once formed,! continues to be one of the con- 
stant symptoms throughout all the stages of the disease. 

After a short continuance of these unfavourable symptoms, 
a general prostration of the system ensues ; the difficulty of 
respiration increases, a copious diarrhoea occurs, numerous 
petechias are formed in different parts of the body, the surface 
becomes cold, and death takes place in some cases as early as 
the second or third day, and in others not until the expiration 
of as many weeks. 

In the active stage of the disease, among other parts that 
participate in the inflammation, is the cellular tissue throughout 
the body, causing a general swelling, hard and resisting to the 
touch, wherein it differs from the serous infiltration which pro- 
duces oedema. This swelling is particularly noted about the 
face, hands, and other flexures of the limbs. When the disease 
has a tendency to terminate favourably, the febrile symptoms 
abate about the fifth day, when the eruption of the skin and the 
inflammation of the fauces also lessen in their violence ; the 
cuticle beginning to separate about two or three days after, at- 
tended with great itching and increased sensibility. These 
symptoms, with the presence of a lateritious sediment in the 
urine, may be regarded as almost certain evidences of conva- 
lescence. 

It has frequently been noticed that a short inflammatory ex- 
citement will follow the separation of the cuticle, and be suc- 
ceeded by a new desquamation ; the excitement is but tempo- 
rary, and can in no instance be regarded as of sufficient severity 
to require any treatment. The bowels which, during the active 
stage of the disease, are costive, become relaxed in conva- 
lescence, and a spontaneous diarrhoea will frequently arise on 
the abatement of the fever. 

The next form of attack which is the most frequent, is that 
in which the brain is the seat of congestion. This is extremely 
sudden and rapidly fatal ; making its appearance without any 
premonition whatever, and often terminating without any evi- 
dence of the return of arterial action. The first symptom is 
that of overpowering cerebral congestion, bearing a resem- 
blance to the sudden effusion in the brain, described by Dr. 
Golis under the name of water stroke. The cause of this con- 



404 DISEASES OF CHILDREN. 

dition of the system is always to be strongly suspected in the 
absence of all pathognomonic signs, when scarlet fever prevails 5 
and during an epidemic the practitioner will rarely be in error, 
when he refers it to the influence of the contagious principle of 
the disease, at once overpowering the vital energies. On other 
occasions a short period of exhilaration will precede this loss 
of nervous power, characterizing the state of congestion. The 
child will appear to be more than ordinarily excited in spirits, par- 
ticipating in its sports with a joyousness so unusual as to attract 
attention, but without any manifestation of diseased excitement. 
Perhaps, after a short time, sleep will overpower him, from 
which he is with difficulty aroused. When placed upon the feet 
he will be observed to stagger ; while a universal inability to 
move the limbs, and an expression of stupidity and indifference 
to all around him, first excite the alarm of the parents. 

When this congested state exists, the surface of the body and 
face is pale and cold, while the lips are swollen and livid. The 
head is hotter than any other part ; the eye-lids are half closed, 
and, when opened, exhibit a dull expression of the eyes. As 
the disease advances the pupils become dilated, a condition 
which often arises early in this disease. It is not always an evi* 
dence of effusion. A great degree of pressure on the brain, from 
whatever cause, will produce the same symptom. 

It sometimes occurs that the cerebral congestion form is 
much slower in its approach, and the patient may be languid 
and pale for some days, all the movements being slow, and 
with appearance of fatigue. The pulse is slow, irregular and 
oppressed. The tongue is white, and the salivary glands 
secrete a thickened saliva. In this state there is a very evi- 
dent derangement in the secretions of the chylopoetic viscera, 
as appears from the flatulent and distended condition of the 
abdomen, and the altered appearance of the alvine evacuations, 
which, for the most part, are much darker than ordinary. 
There also exists a great loathing of food, and an irritable state 
of the stomach. The eruption on the surface is of a dark red 
or purple colour, more in the form of patches, than in the ordi- 
nary efflorescent appearance characterizing the morbid altera- 
tions in the skin. In the sudden congestive form, often no 
eruption appears until after death. 

When this form attacks suddenly, in the manner first de- 
scribed, it is not unfrequently fatal within the first twenty-four 
hours ; when it is slower in its invasion it will terminate fatally 
in from two to five days. The throat is rarely affected when 
the attack is sudden, but if the child should survive the third 
day. small sloughs are found in the fauces, but without much 
traces of inflammation. 



EXCERNENT SYSTEM. 405 

There is another form in which scarlet fever makes its at- 
tack : where the lungs and heart appear to be loaded with venous 
blood, and the blood-vessels are greatly impeded in their action. 
In no instance does it attack the child with the violence of the 
form just described, nor is it by any means regular in its com- 
mencement and progress. It often commences with the usual 
feeling of chilliness, alternating with heat, weariness and head- 
ache. The developement. either of the fever or eruption, is 
not uniform. In general, however, on the second or third 
day, the body and limbs will be covered with a dark red efflo- 
rescence, in some parts inclining to a purple. The surface 
will be intensely, hot to the touch, while the patient, if old 
enough, will complain of a sensation of chilliness. The throat 
early shows the existence of inflammation, and is considerably 
swollen. Respiration soon becomes laboured, the pulse slow, 
small and irregular. The condition of the cutaneous surface, 
the state of the circulation, and the laboured and oppressed 
respiration, clearly indicate the loaded condition of the great 
vessels at the centre of circulation. If blood be taken from 
the arm, or if leeches be applied to the throat, the colour of the 
surface rapid] y undergoes a change from the dark red to a livid 
paleness, even though a small quantity of blood be lost ; the 
pulse becomes smaller, and if the heart does not possess power 
to produce an active circulation, either from its own inherent 
force, or with the assistance of such judicious means as art may 
afford, a fatal debility ensues. This form of congestion rarely, 
if ever, exists, without being followed by that of the brain, some- 
times in the short space of twenty-four hours after the full de- 
velopement of the disease. The face becomes swollen and 
pate, with livid spots where the eruption was the thickest, and 
an irremediable comatose condition indicates the course of the 
disease. 

The latter form assumes every grade of the congesto- 
inflammatory condition, wherein the anginose affection, with 
which the disease commences, is associated with inflammation 
of the bronchial tubes. When this is uninterrupted in its pro- 
gress, the pulmonary system becomes more or less engorged, 
and sometimes very rapidly suffers a complete congestion ; 
this state of the venous system being present in a partial de- 
gree from the commencement, and increasing with the increase 
of the inflammatory symptoms. 

The loss of vital energy, constituting congestion, is not 
always found in the debilitated and delicate, for I have seen it 
attack the most robust, and prostrate the child in thirty-six 
hours. It often appears to depend on the impure air the child 
breathes, and more particularly in confined and damp apart- 



406 DISEASES OP CHILDREN. 

merits, excessively heated. Under these circumstances the 
worst cases of pulmonary congestion, combined with inflam- 
matory action, have occurred ; and when not quickly fatal, the 
usual symptoms of extreme prostration arise : the tongue is 
dry, the teeth covered with sordes, the inflammation of the 
throat becomes livid, extensive sloughs form, and the disease 
assumes the form usually denominated scarlatina maligna. 

With this irregular condition of the system, an irregularity 
also exists with regard to the eruption. It is not uniform in its 
appearance, and is much less diffused than either in the simple 
inflammatory form, or in the true congestive variety, as it oc- 
curs in the pulmonary system. It is also very liable to dis- 
appear after it has once made its appearance, leaving the skin 
pale and livid. 

This form of scarlet fever, when it terminates favourably, 
is remarkably slow in its convalescence ; for the tendency to 
collapse, and the irregularity of reaction, present a continued 
succession of morbid actions to be encountered by the physi- 
cian, for the removal of which his art is too often powerless ; 
and to unresisted nature, after a long period, marked by anoma- 
lous symptoms almost without parallel, he is often compelled to 
leave it, with the simple adoption of the ordinary rules of 
hygiene. 

Besides these varieties of the disease, there has existed a pus- 
tular form, in which the ordinary eruption was complicated 
with pustules. An epidemic of this kind prevailed in France 
in 1777, an account of which is given by Lorry, and was 
extremely fatal. After the usual premonitory fever, accom- 
panied with congestion of the brain and delirium, red spots 
appeared on the hands, arms, loins and face. With them 'the 
disease increased in severity, the body became much swol- 
len, and bore a resemblance to^tanned leather. The patients 
died with all the symptoms of malignant disease, and with the 
body covered with pustules.* Miliary eruption has also been 
complicated with the efflorescence of scarlet fever in some cases, 
although some have been fatal ; yet an abatement of the 
symptoms generally followed the appearance of the eruption.f 
Withering and Rush describe similar symptoms. 

Other varieties have been its complication with great de- 
rangement of the digestive system, and the presence of a large 
number of intestinal worms, which were discharged both by 
the mouth and anus. An epidemic of this nature prevailed in 



* Hist, de la Soc. Roy. de M6d. 

t Institutions of the Practice of Medicine, by John Baptist Burserius. Trans- 
lated from the Latin, by Brown; Edinb., 1801, vol. ii. p. 203. 



EXCERNENT SYSTEM. 407 

the city of Cefalonga, in 1 763.* In other instances, violent pain 
was the most marked symptom, as in the epidemic in Copen- 
hagen, in 1777 and 1778, of which Meza has given an account. 
Morton has given the history of the disease, as attended with 
buboes ; while other epidemics have been characterized by 
ulceration of the throat and genital organs, accompanied with 
miliary eruption, derangements of the biliary secretion, or, as 
above mentioned, with great numbers of worms. These are 
not isolated cases, but the character of prevailing epidemics, 
which arise from the action of the same unknown causes that 
first produce the disease. 

The secondary effects of scarlet fever are dropsical effusions, 
rheumatic affections of the joints, with contraction of the ten- 
dons, and suppuration of the external glands of the neck, and 
purulent discharges from the ear. 

Dropsy. — The dropsy following scarlet fever is often more 
serious than the original disease ; for it is observed to follow the 
mild form, and never what is denominated the malignant. It is 
at times a formidable affection, demanding more of the attention 
of the physician than the disease which precedes it ; for a fatal 
progress may imperceptibly be made, when danger is little 
suspected, and even when, from the extreme lightness of the 
primary affection, a speedy recovery is expected. Every 
physician is familiar with the slowness of what is termed con- 
valescence in scarlet fever, but which,^ from the number of ob- 
stinate symptoms, and their occasionally fatal termination, might 
better entitle it to the name of a distinct stage. 

Dropsical effusion appears in some instances suddenly, at any 
period from the time of the disappearance of the eruption to 
the end of the third week. In the greatest number of in- 
stances, however, after the pathognomonic symptoms have dis- 
appeared, the swelling gradually shows itself, preceded and 
attended with lassitude, fretfulness, and slight febrile excitement. 
At night the little patient is extremely restless and feverish. 
These symptoms will continue for several days, without any 
mitigation or change of any kind, and without the usual symp- 
toms of local disease ; but a general feeling of uneasiness ap- 
pears to pervade the system. The face and lower extremities 
first give evidence of the existence of serous effusion in the 
cellular membrane, which is gradually filled in every part of 
the body. Effusion, also, occurs in the large cavities ; and as- 
cites and hydrothorax, in severe cases, accompany the other 
species of dropsy, and usually precede a fatal termination of 
the disease. 

* Burserius, Op. Cit. 



408 DISEASES OF CHILDREN. 

When anasarca is unattended with febrile excitement, there 
is but little danger to be apprehended, although the serous fluid 
may be extensively diffused. When, however, there exists much 
heat of skin, thirst, restlessness, and general uneasiness, it de- 
mands early and prompt attention ; for these symptoms will not 
long continue without being followed by local inflammation, 
congestion or effusion, in important parts, often terminating 
fatally. If possible, these should be anticipated ; for when 
once they are established, there is a great difficulty in their 
removal, complicated, as they are, with a general affection, 
which embarrasses the action of the whole circulation. It 
rarely happens that this febrile action continues even for a 
short time, without tenderness of the abdomen, vomiting, inter- 
rupted respiration, or a dry cough following ; and the patient 
either sinks under the accession of a violent inflammation, or 
from the effects of excessive effusion, in some of the important 
cavities. 

The urine, in cases of dropsy following scarlet fever, exhibits, 
by its coagulation by heat, the presence of albumen. Its specific 
gravity is much less than usual, and its colour differs materially 
from the straw colour which is the characteristic of healthy 
urine. It bears a greater resemblance to serum or whey, and 
is occasionally of a reddish' hue, and small in quantity. 

Rheumatic Affections of the Joints, with Contractions 
of the Tendons. — These are by no means so common as the 
sequela above mentioned. On the disappearance of the erup- 
tion, a pain in the wrist, hand, or knee, will be felt, attended 
with a slight inflammatory blush. Occasionally the pain is very 
severe, and will not admit of the extension of the affected mem- 
ber. These rheumatic affections are most likely to occur where 
there is an hereditary tendency to the disease. 

In some cases the rheumatic inflammation will terminate in 
contraction of the tendons, of long duration and obstinacy, caus- 
ing considerable deformity ; and if occurring in the tendons 
about the knee, renders the child unable to walk without the 
assistance of a crutch. 

Suppuration of the External Glands of the Neck, and 
Purulent Discharges from within the Ear. — These are of 
frequent ocurrence in children of a scrofulous habit. The for- 
mer commences with the usual signs of inflammation on the 
subsidence of the febrile affection, and is very obstinate and long 
•continued, like Gther sequelae of this disease. 

The purulent discharge from the ear is, in most instances, 
preceded by a partial loss of hearing during the continuance of 
the eruption. Whenever the throat is much inflamed, the in- 
flammation is liable to extend through the Eustachian tube. In 



EXCERNENT SYSTEM. 409 

a few days after the violence of the symptoms have disappeared, 
a slight discharge of purulent matter from one or both ears 
will show itself. It is often followed by a permanent deafness 
more or less severe, from a thickening of the membrane lining 
the Eustachian tube, and a partial closure of this passage. 

Morbid Anatomy and Pathology. — In most cases of this 
disease that have been subjected to post-mortem examination, 
the capillary vessels of the mucous coat are found injected or 
ulcerated. These are more often found about the pharynx and 
fauces than in any other part of the alimentary track. The in- 
jection often appears in the form of streaks of a crimson colour, 
varying to a brown or livid hue ; the latter being more intense 
in and about the tonsils and soft palate, which are more frequent- 
ly found in a sloughing state than any other diseased part. 

This inflammation is also found in the greatest number of in- 
stances to occupy the air-passages ; and even extensive ulcera- 
tion has been discovered in the trachea, with almost an entire 
destruction of the larynx by the ulcerative process, and this 
without much disorder of the system other than attends croup, 
the peculiar symptoms of scarlet fever having disappeared. 

In other instances but little traces of inflammation have been 
found after death, although excessive secretion of mucus has 
occurred during life ; no other morbid appearances existing, 
besides the presence of this morbid secretion filling the trachea 
and bronchi se, together with slight effusion of serosity in the air- 
cells. Besides this, it is not unusual to find the air-passages 
filled with a muco-purulent matter, with marks of inflammation 
about the lungs and pleura. These parts are also at times, 
especially when the disease has been protracted, in a thickened 
condition, with deposits of coagulable lymph. 

In some, the brain is also more or less extensively diseased. 
The vessels, especially of the membranes, are injected, and 
effusions of turbid lymph are seen between the arachnoid and 
pia-mater, and serosity in the ventricles. This is more uni- 
formly found to be the case where the disease has been attended 
with a sanious discharge from the nose, and with the collection 
of sordes around the teeth. 

In congestive cases, there are little marks of capillary injec- 
tion, but the larger vessels are loaded with blood, especially the 
lungs, liver and brain, which are distended with dark venous 
blood ; and in almost every ease of congestive scarlet fever no 
other lesion can be discovered. 

A great difference, therefore, is observed in cases of this 
disease, according to the different forms it assumes. In the 
strictly inflammatory form, there are the usual evidences of in- 
flammation in the mucous tissues ; such as redness, thickening, 

52 



410 DISEASES OF CHILDREN. 

ulceration, effusion of muco-purulent matter, and sloughing of 
the diseased parts. In those characterized by congestion and 
sudden death,jio such lesions exist ; but. evidences of an entire 
arrest of the circulatory process are seen in the loaded condi- 
tion of the vessels at the fountain of circulation, and in the dark 
colour of their contents. In such as partake of the nature of 
both, a great variety in the appearance of the various tissues 
and cavities are found, when probably there is no disease pre- 
senting so extensive morbid conditions. 

It has been also supposed that a change has occurred in the 
fluids, from the influence of the miasma on the blood, whereby 
an alteration is wrought in its constituents, and rendering the 
serum incapable of holding the albumen in solution, which 
causes the exudation on the inflamed surfaces. Some changes 
appear to be made in the blood ; for in one severe case, where 
the disease manifested itself in a sudden congestion of the heart 
and pulmonary system, a small quantity of blood which I took 
from the arm had more the consistence of dark paint than of 
blood which usually flows from a vein. Its coagulation also 
was imperfect. This child died in less than twenty-four hours ; 
cerebral congestion very quickly following the primary attack. 

It has also been said that the secretions become acid in scarlet 
fever. Of the truth of this I am unable to speak from expe- 
rience. I have often, however, tested the serum of the blood 
with litmus paper, without discovering the presence of any acid. 

As to the morbid condition of the dropsy following scarlet 
fever, it is unquestionably inflammatory : exudations of lymph 
having been found on the peritoneum, covering the liver, and in 
other parts of the body. This view of the nature of the dropsical 
swellings occurring after scarlet fever, was noticed long since, 
for Burserius remarks,* that in the epidemic, about the year 
1717, in Florence, after the mild form of the disease, which re- 
quired no other treatment than Sydenham's mild method, a 
universal swelling occurred, attended with a slight pain in the 
chest, tormina of the abdomen, and suppression of urine. 
" These patients, having been previously treated with diuretics, 
were speedily carried off. After this, the dead bodies being 
opened, it was found that the lungs, pleura, intercostal mus- 
cles, diaphragm, kidneys and intestines, were more or less 
inflamed." This is a remarkable corroboration of the facts elicit- 
ed at different times by autopsical examinations ; inasmuch as 
it clearly and distinctly points out the condition of the parts 
examined, at a period when anatomical investigations for as- 
certaining pathological changes were by no means frequent, or 
remarkable for their accuracy. 

* Op. Cit., p. 433. 



EXCERNENT SYSTEM. 411 

Dr. Bright discovered in the kidneys of those who died of 
dropsy, with albuminous urine, which occurred after scarlet 
fever, an irregular congestion, without any apparent lesion of 
structure; but in some cases where a foundation had been pre- 
viously laid, the more usual appearances of advanced structural 
derangement were ascertained. In one case which he reports, 
the kidneys were of a natural size, the tunics adherent, and the 
cortical portion much mottled, with a white deposit. Conges- 
tion, especially in the tubular portion, was the most marked 
symptom.* 

On the subject of the pathology of the disease there exists no 
little obscurity, and consequently a difference of views — some 
maintaining that it is an essential fever, with a rash and inflam- 
mation of the mucous surfaces arising as a consequence or an 
effect of this excitement; others, that it is originally a morbid 
state of the gastric mucous membrane, which is previously af- 
fected with inflammation, and which is extended to other mu- 
cous membranes in proportion to the intensity of the primitive 
disease. 

The latter view appears more in accordance with the facts 
as they usually occur ; but it is not always that the morbid 
phenomena are previously manifested in the gastric mucous 
membrane, for the pharyngeal and oesophageal portions of the 
alimentary canal are those which first give evidence of the 
disease, in many instances, without any of the usual marks 
of gastric inflammation. In other instances a tenderness of 
the epigastrium on pressure, and the functional disturbance of 
the stomach, show the existence of inflammation in its mucous 
coat. In by far the greatest number of cases, the first appear- 
ance of the inflammation arises in the fauces ; the tonsils are 
red, even where the tongue and other parts of the mouth are but 
slightly, if at all, inflamed ; but where the former are enlarged, 
and deglutition difficult, the tongue and buccal membrane are 
proportionably inflamed. From the well-known sympathy 
which exists between the mucous surfaces, the disease soon 
rapidly spreads throughout the membranes lining the various 
surfaces, and to the cutaneous covering of the body, which is but 
a continuation of the former. 

An erythematic inflammation, or an overloaded state of the 
capillaries of the mucous membrane and outer surface of the 
cutaneous chorion, is the character of the morbid phenomena of 
ordinary scarlet fever, of different degrees of severity, occur- 
ring on the reaction arising after the first impression of the se- 



* Dr. Bright's Cases of Renal Disease, cited in Johnson's Med. Chir. Review 
for July, 1840. 



412 DISEASES OF CHILDREN. 

dative effects of the infectious principle on which the disease 
depends. The simple form is the mildest variety of erythema- 
tic inflammation, and often exists with scarcely any febrile action, 
and with very little disease of the mucous chorion. In the 
more violent forms there is much greater disturbance of the 
vital functions ; and when a great determination of blood occurs 
to the surface, it sometimes happens that effusions of coagu- 
lable lymph take place in the papulous elevations, bearing a 
great resemblance to the eruption of varicella. Dr. Rush* has 
described this variety of the eruption, besides the older writers 
already mentioned. 

The congestive form is evidently from the sudden and pow- 
erfully depressing influence of the morbific cause, depriving the 
organs of their vital force, and thus causing a congestion of the 
larger vessels. This is always the first impression miasmata 
of any kind make upon the system, as is evident from the de- 
bility and lassitude so common on the first invasion of disease 
from these Gauses. If reaction, either partial or complete, do 
not take place, a congestion ensues, producing the most violent 
forms of scarlet fever, which are, for the most part, speedily 
fatal. The German physicians consider this condition as pro- 
duced by a species of narcotism, and as distinct from the 
congestion of Armstrong. But the two ideas may be easily 
reconciled, by regarding the poisoning influence of the conta- 
gion .as depriving the heart and blood-vessels of a portion of 
their vitality, and producing thereby a congestion, from their 
inability to act when thus depressed in their vital energy. 

Treatment. — The simplest form of disease scarcely re- 
quires any remedy, and is so entirely free from danger, that, 
according to Sydenham, it only becomes dangerous from the 
officiousness of the medical attendant. It is often so mild as 
scarcely to attract the attention of the parents, and the child 
is suffered to pass through it without any medicine what- 
ever. It is, however, precisely such cases that are the most 
frequently followed by dropsy, and, therefore, it should be our 
duty to prescribe something that will tend, at least, to pre- 
serve a free secretion from the mucous glands of the intestines 
and the annexed viscera. Suitable aperient medicine should 
therefore be given, especially when the eruption is at its 
height, and on its decline; and the danger of subsequent serous 
effusion, which, as is seen above, is uniformly dependent on a 
phlogosed state of the serous membrane, will be greatly lessened, 
if not entirely removed. A simple dose of castor oil, or the 
eccoprotic mixture, repeated after an interval of three or four 



Med, Inq., p. 123, 



EXCERNENT SYSTEM. 413 

days, will be sufficient to produce the effects. The subject of 
the management of dropsy will necessarily come under the 
proper head ; for the present, it is only alluded to in speaking 
of the treatment necessary in the mildest form of the disease, 
which so generally precedes the dropsical effusions. 

Besides the employment of aperients, a cooling course of 
regimen will be the most proper ; and should the heat of the 
surface be very high, tepid or cold sponging will be the most 
proper measures for lessening the morbid action of the cutane- 
ous vessels. It is in such cases that the cold effusions are 
beneficial ; they are scarcely applicable to cases where there 
exists much inflammatory action. It is the duty of the physi- 
cian, however mild the attack may be, to bear in mind the 
possibility of the appearance of inflammatory symptoms, and 
to be prepared to meet them ; for it is a disease remarkably 
varying in its character, and although in many instances need- 
ing but little treatment, yet in others a steady, but slow aggra- 
vation of symptoms takes place, ultimately demanding the 
closest attention, and the exercise of the greatest discriminating 
judgment in its treatment. 

The inflammatory form of the attack, which will necessarily 
include that change of symptoms just mentioned, next de- 
mands our attention. Upon the proper management of this 
will depend the removal of those serious organic lesions so 
often occurring in protracted cases of this disease. 

Among the most prominent remedies for the relief of the 
inflammatory symptoms, is blood-letting ; a remedy which has 
been lauded as the only one which can be relied on for the 
removal of violent attacks of scarlet fever, and which has also, 
even in the same epidemic, been condemned as of great hazard, 
from its inducing a state of debility which so often characterizes 
long continued cases of this disease. When judiciously used, 
especially with respect to the proper time for employing it, it 
is often a very efficient remedy ; but when this proper time has 
passed over, or where the symptoms, although of an inflam- 
matory nature, do not positively indicate its use, it may in the 
former case, indeed, fail of affording the desired relief, and in 
the latter, be advantageously superseded by other means. It 
is of the most vital importance that the primary stage, or period 
of active inflammation, wherever this inflammation is located, 
be selected, as affording the proper proof of the efficacy of 
venesection ; for if it be left until local congestion or disorgani- 
zation have taken place, although in the one case some alleviation 
may occur, yet in the other an aggravation of the symptoms 
will almost invariably ensue. Dr. Armstrong has found bleed- 
ing an indispensable agent in the treatment of this disease at the 



414 DISEASES OF CHILDREN. 

commencement, preventing thereby the consecutive effects 
which are the cause of death. Numerous instances of the 
beneficial effects of bleeding, are recorded in the different medi- 
cal journals in our country. 

Dr. Mcintosh, in his valuable work,* says, "I saw many 
fatal cases of scarlet fever when I practised according to the 
opinion of the schools, carefully abstaining from blood-letting, 
and using all the means recommended to support the strength." 
The accomplished American editor, Dr. Morton, sustains him 
in his views as to the advantages of blood-letting. 

The opposite opinion has been maintained by others ; and 
among these, Evanson and Maunsell appear to disapprove of 
its use, but qualify their disapprobation by remarking, that it 
can only be employed as a resource, in cases where there is 
a decided local inflammation, and then only barely sufficient 
for its control. This, however, seems to be an admission of 
the benefits derived from the use of this remedy. In our 
country it is said also to have been attended with the most 
fatal effects, as was the case in the epidemic which prevailed 
in Virginia, in 1832.f It is well known that others have held 
similar views, and from non-success in the depleting plan, have 
had recourse to an ultra-tonic system. In our recent epidemics, 
the mild, stimulating course, was in many instances attended 
with success. J 

All. these show that the exercise of a sound judgment is 
necessary, and that for want of a sufficient discrimination, 
bleeding has been too general. There will never be any diffi- 
culty in obtaining blood in sufficient quantities from the leech 
bites, in consequence of the highly injected state of the vessels 
of the skin. The use of leeches may frequently be resorted 
to, according to the circumstances of the case, during the 
course of scarlet fever ; and, indeed, there is scarcely a remedy 
more appropriate than capillary bleeding, where all the symp- 
toms evince so complete a sanguinary injection of the capillary 
system. It is sometimes needed to unload the bowels ; but the 
employment of active purgatives may be counter-indicated by 
the phlogosed condition of the mucous membrane, from accumu- 
lation or congestion in its capillary vessels. Under these cir- 
cumstances, therefore, the relief by leeching is often well 
marked, and this course very properly prepares the body for 
the use of other and more direct measures. 

One of the most powerful means of treating scarlet fever, is 

* Principles and Practice of Physic, vol. i. p. 189. 
t Dr. Magill, in Amer. Journ. Med. Science, vol. xxiv. p. 342. 
t See Dr. Cornell's Account of Ninety Cases, which were treated by him; N. Y. 
Journ. of Med. and Surg., for January, 1841. 



EXCERNENT SYSTEM. 



415 



the early administration of an emetic, if the tenderness of the 
epigastrium do not forbid its use ; and where the disease spends 
its force more on the pulmonary system than on any other part, 
the benefits are immediate, and often permanent ; a powerful 
revulsion being made on the cutaneous surface, and the air- 
passages being also relieved of their accumulation of mucus, 
the strong tendency to internal congestions, which exists in this 
disease, is removed. 

Emetics have been restricted to the commencement of scar- 
let fever by some practitioners ; but by such a course we deprive 
ourselves of a most powerful means of relieving at least one 
very distressing symptom, the accumulation of viscid and 
tenacious mucus, which often threatens a child with suffocation. 
Emetics should, with judgment, form a part of the treatment in 
a majority of the cases of scarlet fever : in those cases where 
there is no congestion of the head, nor any gastro-enteritis 
present. In the inflammatory scarlet fever, after sanguineous 
depletion, either generally or locally, the employment of an 
emetic will very materially tend to allay local inflammation, by 
equalizing the circulation, and opening the cutaneous secretory 
vessels, and especially does it relieve the inflammation of the 
tonsils and fauces by causing a free secretion from these surfaces. 

It is on this account that emetics, at the commencement of 
the anginose variety of scarlet fever, are so universally employed. 
Writers of almost every period, and in every country, bear 
testimony to the good effects of emetics. In slight affections 
of the fauces, they will completely arrest the morbid action, 
without the intervention of bleeding in any form. Emetics, 
in long continued cases, it has been observed by a practical 
author, are the best gargles for cleansing the throat and fauces, 
and removing the morbid secretions in the ulcerated and 
sloughed condition of these parts. In this stage, also, they 
are useful, by cleansing the stomach from the sordes and other 
morbid secretions, and thus preventing the prostrating diarrhoea, 
which is of so frequent occurrence at a late period of the disease. 

Where there is much inflammatory action, tartar emetic and 
ipecacuanha may advantageously be combined, especially at the 
commencement of the disease,* and also with squills where there 
is much bronchial affection.f Where there is much prostration, 
or, in advanced stages of the disease, where the debilitating 



* fy Pulv. Ipecac, 3j. 

Vin. Antim., 3j. 

Aquae Destill., §ss. 

Syrup., §ss. M. 
A teaspoonful every ten minutes, to a 
child two or three years old. 



t fy Pulv. Ipecac, 3j. _ 

Antim. Tart., gr. j. 

Oxymel. Scillee, 

Syrup. Simpl., aa. gss. 

Aquae, §j. M. 
A dessert-spoonful every quarter of an 
hour, for children five or six years of age. 



416 DISEASES OP CHILDREN. 

effects of an emetic are to be apprehended, ipecacuanha may be 
combined with sulphate of zinc, in the proportion of a quarter to 
half a grain of the latter, to three or four grains of the former, 
every ten or fifteen minutes, to a child a year old. But in the 
use of emetics in this disease, it is almost impossible to designate 
with any accuracy the quantity which will be required ; the 
coating of the stomach, from the viscid secretions, rendering it 
difficult in some instances to procure any effect from medicine 
given in the usual quantities. I have known more than double 
the ordinary dose for an adult to be given to a child of five 
years of age, and repeated frequently, without producing any 
effect. Dr. Rush prescribed emetics combined with calomel. 

There scarcely exists any necessity for the active purging so 
freely resorted to some few years since, when it was con- 
sidered a necessary part of the treatment. It may, however, 
be active in proportion to the violence of the inflammatory 
symptoms, if the gastric inflammation do not forbid its employ- 
ment. Where it is necessary to relieve the bowels, the subjoined 
formula will be eligible,* particularly if there be any tendency 
to congestion; or castor oil, an infusion of senna, sulphate of 
magnesia, or manna, and super-tartrate of potash may be used, 
for effecting the same object. Throughout the disease the 
bowels must be kept soluble by any eccoprotic mixture, or by 
an enemata. 

Among the depletory measures, when there exists much de- 
bility, is the action of diuretics recommended by Withering ; 
sub-carbonate of potash was used by him for this purpose with 
much advantage. 

An antiphlogistic course, early adopted and efficiently used, 
will in this, the most common form of scarlet fever, prevent the 
disease from assuming the typhoid symptoms, and the disorgani- 
zation of structure so much dreaded. The adoption, however, 
of the depleting system requires the exercise of much prudence, 
that it be well timed and regulated according to the age, con- 
stitution and habits of the patient, and also with reference to 
the nature of the prevailing epidemic. This influence produces 
its effects by modifying the disease, from the simple inflamma- 
tory type, to a state of congestion, more or less complete, 
whereby it exhibits all the different phases of congesto-inflam- 
matory form. Under these circumstances, great caution is 
necessary; for in proportion to the existence of congestion, 

* # Pulv. Rhei, 

Sods Sup. Carb., aa. gr. xv. 
Pulv. Ipecac, gr. j. M. 
Divid. in Pulv., No. vi. 
One powder to be given every two hours, until it affects the bowels. 



EXCERNENT SYSTEM. 417 

should we be careful in the sudden abstraction of blood, for 
although the relief of the blood-vessels is necessary, yet this 
congestion is an evidence of the loss of vital energy, which 
will not admit of sudden or great loss of blood. 

The ordinary diaphoretic treatment usually adopted in fe- 
brile affections is of little avail in this disease, from the con- 
tinual high temperature of the surface. Antimony, however, 
has been used, in cases of high excitement, with benefit. 

With respect to the local treatment of the inflamed tonsils, 
it must be directed according to the existing condition of the 
part. When the inflammation is high, the application of 
leeches, as already spoken of, is indispensable. Blisters have 
been recommended, but they should never be applied, from 
their great tendency to become gangrenous. Poultices are 
useful applications at every period of the inflammation. 

When ulceration and sloughs appear in the throat, stimulating 
gargles will become necessary, made with infusion of sage, 
tincture of myrrh, and decoction of bark ; or, where the sloughs 
are separated with difficulty, they may be touched with some- 
thing more stimulating, as burnt alum, or nitrate of silver. 

In general, the local management of the diseased tonsils 
differs in no respect from that already given when treating of 
cynancbe maligna, to which this disease bears so close a re- 
semblance in one stage, as to have been regarded as the same 
affection. 

As was before remarked, the abstraction of vital power is 
sometimes, from the peculiar action of the epidemic influence, 
very sudden, and collapse very quickly ensues after an attack. 
In such cases but little if any inflammatory action occurs ; but 
where there is much inflammatory developement, the stage of 
sinking and collapse is much slower in its approach, and is not 
likely to be extreme where suitable antiphlogistic measures 
have been pursued at the commencement. Whenever it takes 
place, it will be necessary to resort to mild stimulants to arouse 
the circulation to its wonted vigour. 

One of the best and most natural stimulants is the influence 
of pure air. The room of the patient should, therefore, be care- 
fully ventilated, and every thing that can in any w T ay render it 
impure must be removed. Wine whey should be cautiously used, 
and its effects watched. Infusion of serpentaria is very valuable, 
from its tendency to excite diaphoresis, while it exerts a stimu- 
lating effect upon the heart. When the collapse is excessive, 
with a feeble action of the capillary system, the administration 
of camphor will be found highly useful. When, therefore, 
there is a great prostration of the vital powers, manifested by 
a weak and tremulous pulse and a cold surface, it will be found 

53 



418 DISEASES OF CHILDREN. 

advantageous, especially when combined with musk, from its 
qualities of increasing the activity of the nervous energy. It 
may be given to an infant in the dose of one half of a grain, 
and from one half to one grain to children from two to four 
years of age. One of the best forms of its administration is the 
mistura camphorse of the dispensatories, or the camphor julep. 
Another mode of giving it is by rubbing it up with milk, which 
completely suspends it, and thus renders it easy to swallow ; 
or it may be given suspended in mucilage.* In these cases, 
and where there is a recession of the eruption from any cause, 
it is useful as an external stimulant, applied by rubbing the sur- 
face briskly with a piece of flannel, moistened with a saturated 
solution made with alcohol. Stimulating frictions of the tincture 
of capsicum or brandy, care being taken that it be kept hot, 
and that the skin be not cooled by its evaporation, will also be 
useful in cases of collapse. 

Where a prompt and vigorous excitement is needed, the 
sesqui-carbonate of ammonia may be employed : it is a power- 
ful stimulant, and more especially applicable to those cases 
characterized by a great diminution of sensibility and a small 
and scarcely perceptible pulse. Dr. Peat recommends it in 
scarlatina maligna almost as a specific, in large doses. It is, in- 
deed, a valuable medicine where the disease is marked by un- 
equivocal symptoms of debility, with sloughing of the throat 
and tonsils. It should be given in a solution, in the form of an 
emulsion with mucilage, in the dose of two to four grains to 
children from four to seven years of age.f 

The form of attack known as the sudden congestive invasion 
of the brain, is almost invariably fatal : whatever is prescribed 
appears to be of little effect, for effusion and death soon occur. 
In those, however, which have been preceded for some days 
by languor, a foul tongue and a costive habit of body, although 
the attack of cerebral disease may appear to be sudden, yet 
there is some prospect of relief, if the appropriate means be 
promptly and judiciously used. Although the abstraction 
of blood may be necessary for the relief of the congested ves- 
sels, yet it ought to be carefully done, and the condition of the 
patient closely watched, and other measures combined, until suf- 
ficient reaction be restored to the arteries to warrant a more 
decided and free loss of blood. 



* fy Camphor., gr. iv. I t ^ Ammonise Sesqui-Carb., gr. viij 



Mist. Acacias, 
Syrup., aa. gss. 
Misce et adde, 

Aquae Flor. Aurantii, gj. M. 
A teaspoonful every two hours. 



Mist. Acaciee, 
Syrupi, aa. 3ss. 
Aquae Anisi, 3iij. M. 
A teaspoonful every hour. 






EXCEENENT SYSTEM. 419 

When the physician is called to this form of scarlet fever, it 
becomes his duty to remain with the patient, that he may be 
ready to avail himself of the proper periods of action ; and 
there is no disease where there exists a greater necessity for 
the exercise of a sound judgment. The entire reliance on one 
course of treatment is probably the great cause of failure ; 
whether that course be the local or general abstraction of blood, 
or the use of stimulants and tonics. Under no circumstances 
of the congestive form can any general course be prescribed, 
and the patient left at the commencement of the attack; but a 
close watching of the symptoms becomes necessary, and the 
treatment regulated according to the existing circumstances. 

The objects to be attained are the unloading of the congested 
vessels, and the restoration of the action of the heart ; and it 
requires some judgment accurately to decide whether we are 
first to resort to bleeding, either locally or generally, or en- 
deavour in the first place to excite some action and revulsion 
on a remote part, before resorting to a remedy which, while 
it unloads the vessels, will at the same time lessen the vital 
forces. 

The safest course is, probably, to immerse the lower extre- 
mities in a stimulating bath of Cayenne pepper, to envelope the 
body in flannels wrung out in hot salt and water, and to apply 
a sinapism on the epigastrium, giving, at the same time, a full 
dose of calomel. That no time be lost, a stimulating enema of 
a solution of salt, or an infusion of senna, will not only have the 
effect of producing a revulsion on the intestines, but will also 
act in some degree as a stimulant to the system, and relieve 
the loaded vessels. After a sufficient time has elapsed, the 
operation of the calomel may be promoted by the use of castor 
oil, or an infusion of senna and manna and salts, the action of 
which will greatly relieve the congestive tendency, especially 
when it has been ascertained that there has for some days 
previously existed a general torpor of the chylopoetic viscera. 
It is only to produce this decided effect that calomel is admis- 
sible at the commencement of the disease. A continued use 
of this article is attended with great hazard in increasing the 
morbid action of the mouth and fauces, and hastening the 
sloughing of these parts. Except, therefore, in the congestive 
form, other cathartic substances, which are also less liable to 
create a general disturbance of the nervous system, may with 
more advantage be used. 

Under this course, some degree of reaction will probably be 
observed, when bleeding, either by leeches or by opening a 
vein, is indicated. The blood should be carefully and slowly 
abstracted, and the effects on the circulation ascertained, by 



420 DISEASES OP CHILDREN. 

keeping the finger on the pulse. If this evidently sink, it will 
perhaps be necessary to administer some mild stimulant, as 
wine whey or snake root. The latter is peculiarly calculated 
to augment the energy of the vascular system, whenever it 
needs support, and where, at the same time, it will scarcely 
bear the excitement of an active stimulant. In eruptive dis- 
eases, under the circumstances now under consideration, where 
an action on the cutaneous surface is needed, it is highly 
valuable, as it promotes the functions of the skin. Camphor, as 
before remarked, when speaking of collapse, which possesses 
a similar action, may also be beneficially prescribed when a 
mild stimulant is needed, and the action of which on the sur- 
face is desired. Serpentaria may be used in infusion, made 
with a drachm to four ounces of water, of which a table- 
spoonful may be given every two hours to a child of five or six 
years. When the sinking is great, and the danger from this 
state is imminent, ether may be combined.* In the manage- 
ment of these cases, the object is both to unload the vessels, and 
give them an opportunity of contracting and acting on their 
contents, and to preserve the system from any further loss of 
vital pow T er. 

These are only to be obtained by closely watching the 
effects of the means used, and to lose no time in taking advan- 
tage of opportunities as they arise, for promptly meeting the 
morbid conditions, as they are indicated by the symptoms. 
The loss of too great a quantity of blood, or its too sudden 
abstraction, may place the patient beyond hope. It therefore 
needs the nicest judgment, as well in respect to the quantity 
taken, as in the precise period of the disease at which this 
remedy should be resorted to. 

It may in some instances be best to commence the treatment 
by bleeding ; but whether this be resorted to at the commence- 
ment or not, the application of external revulsions, in the form 
of sinapisms, or simple warmth applied by means of a flannel, 
wrung out in hot water, should never be neglected, as upon 
them will very materially depend the restoration of arterial 
action. On the contrary, the use of internal stimulants may 
be required only in very few instances, and as a general rule 
only where the pulse is observed to be rapidly sinking, and 
where a greater loss of vital energy is evidently taking place, 

* R< Rad. Serpent., 3vj. 
Aquae Fervent., gviij. 

Infuse for four hours, and when 
cold, add 
Spts. Ether. Sulph., 5j. M. 
A dessert-spoonful every hour. 



EXCERNENT SYSTEM. 421 

instead of the reaction, which it is our object to effect by re- 
lieving the loaded vessels. Any of those above mentioned, 
with warm, stimulating drinks, should be given, until the pulse 
rises ; a further, but cautious abstraction of blood may then be 
made, while the surface is preserved warm. 

Where the head is preternaturally hot, cold may be applied 
after reaction has commenced, while warmth is continued to 
the lower extremities. This also requires some caution, as the 
too sudden lowering of the temperature, like the loss of blood, 
will but add to the loss of vital power, on which the conges- 
tion depends. 

It is only by thus ascertaining, from actual experience in the 
individual case, what the system will bear, that we can hope 
to be successful in cases of congestion. This state is not to be 
overcome by leeching alone, so indiscriminately resorted to in 
almost every case of this nature, as the experience of every one 
will fully testify ; but by a judicious combination of those mea- 
sures which will directly relieve it, and such as by their stimu- 
lating action on the heart will indirectly contribute to effect 
the same object ; for this state differs from inflammation, where 
such measures are incompatible. In these sudden cases, 
therefore, nothing can justify the physician in leaving his pa- 
tient, until he can with safety direct a course of treatment 
which needs no change, at least for several hours : until he has 
seen reaction established, or the patient is in reality beyond 
the resources of art. 

These remarks are also applicable to the other form of con- 
gestion above described ; that of the pulmonary system and heart. 
It would appear, however, that the loss of blood is less apt to be 
followed by reaction than in congestion of the brain ; at least 
this is the result of my experience. The skin, from being highly 
injected and of a deep red, will suddenly become pale and 
mottled, after the loss of a very small quantity of blood, even 
by the leeches which have been applied around the throat, while 
no action takes place in the arteries to supply this loss, which the 
rapid sinking of the pulse and greater difficulty of respiration 
evince. The reasons just urged for a judicious combination of 
remedies, apply, therefore, with equal, if not with greater force, 
to the form of the disease now before us ; for the simple abstrac- 
tion of blood appears scarcely to have any other, effect than to 
drain off the blood from the cutaneous surface, to lessen the 
heat of the body, and to lower the vital powers. The treat- 
ment of such cases can differ but little from the other form of 
congestion. 

With regard to the congesto-inflammatory symptoms which 
the disease so frequently exhibits, and those occasional compli- 



422 DISEASES OF CHILDREN. 

cations which we have seen sometimes attend the disease, the 
different measures which are suited to the most prominent mor- 
bid conditions are those which the physician, according to his 
judgment, is to adopt. No positive directions can be laid down, 
and no other rules adopted than the general principles of science, 
keeping in mind that congestion of important organs is far more 
dangerous than simple inflammatory action. 

The treatment of dropsy following scarlet fever is of con- 
siderable importance, from its extreme obstinacy, and at times 
fatal termination. This tendency may be induced by the pre- 
mature use of tonics, as well as by the exposure to cold and 
damp air. It has been remarked that it is more common in the 
colder seasons of the year, and is unquestionably connected 
with the tender and susceptible condition of the skin remaining 
after the inflammatory state, which exists more or less in every 
case of scarlet fever. 

Bleeding from the arm, early in the disease, is the most effi- 
cient means of breaking up the morbid condition on which the 
disease depends ; and a decided impression will be at once made 
on the circulation, and the system thus prepared for the action 
of other remedies, if the swelling do not at once disappear. 
Next to bleeding is the application of leeches over the seat of 
the kidneys, and the flowing of blood should be maintained for 
two or three hours after they have separated. These, however, 
should never be relied on when there is any febrile action, 
where a vein can be opened. In severe cases this is indispen- 
sable, when the blood should continue to flow until the pulse 
gives evidence of the effect on the circulation. After this, the 
use of diuretics becomes necessary, if the secretion from the 
kidneys be not restored by bleeding. A solution of the acetate 
of ammonia, combined with spirits of nitre and a small quantity 
of tartarized antimony, will be found one of the most efficacious 
adjuncts to venesection for a speedy removal of the disease, 
especially if accompanied by the use of the warm bath. Nitrate 
of potass or digitalis will sometimes act on the kidneys when 
other measures have failed. A solution of supertartrate of potash, 
properly sweetened, is also a useful drink, and which children 
very easily take. Its purgative and diuretic properties render 
it highly useful when there is much febrile excitement. 

There are some rare instances in which there exists rather 
a relaxed and debilitated condition of the body, marked by an 
absence of all febrile action. This leuco-phlegmatic state is 
a very uncommon occurrence, dropsy seldom being unconnected 
with some evidences of febrile irritation. The German physi- 
cians advise the more stimulating diuretics, such as squill, tinc- 
ture of cantharides, or spirits of turpentine ; and it has been 
necessary in some cases to resort to tonics, where other mea- 



EXCERNENT SYSTEM. 423 

sures have failed. Calomel, in large doses, sufficient to ope- 
rate on the bowels, has also been used and considered as the 
most effectual remedy. 

Where diuretics will not affect the kidneys, an attempt may 
be made in severe cases to carry off the superabundance of 
fluid by the skin. Dr. McLean, many years since, in the New- 
York hospital, succeeded under the most unpromising circum- 
stances, with the warm bath, followed by Dover's powder. A 
most copious sweating follows the use of these measures, and 
an entire relief to all the dropsical symptoms. To an adult he 
prescribes five grains of Dover's powder every two hours, until 
four doses are taken. 

In the inflammation of the ear, attended with a discharge, the 
application of leeches, and a large emollient poultice, covering 
the whole of the ear and the punctures of the leeches, are the 
best remedies when the affection is discovered early. These, 
with a strict attention to the state of the bowels, will prevent all 
unpleasant symptoms. The early use of these measures can 
only be resorted to when the child is old enough to give timely 
notice of the presence of pain in the ear. In young children, 
tedious suppuration is very apt to occur ; the use of poultices, 
and frequently syringing the ear with warm water, will gene- 
rally effect a cure. In very obstinate cases a blister behind 
the ear will become indispensable, and a permanent discharge 
from the blistered surface should be kept up, until the symp- 
toms are alleviated. In chronic cases, a weak solution of sul- 
phate of zinc, or of the nitrate of silver, may be necessary to 
change the action of the secreting vessels of the part. The 
fauces should be carefully examined, and if chronic inflamma- 
tion or ulceration continue, nitrate of silver should be applied f 
as the affection of the internal ear is sometimes kept up by con- 
tinuous sympathy. 

The rheumatic affection is sometimes very severe ; it is best 
treated with the warm bath, diaphoretics and purgatives. The 
tincture of colchicum, so beneficial in ordinary rheumatism, 
may be advantageously employed in the treatment of this form, 
as it combines many qualities which render it applicable to the 
sequelae of scarlatina, which is characterized by great irrita- 
bility, febrile action, and often a suppression of the urinary 
secretion. 

The rigidity and contraction of the tendons of the muscles is 
sometimes very great, and of long duration. Frictions, with 
stimulating liniments, are the means usually resorted to for the 
removal of this affection. In one very obstinate case, where 
the flexor tendons about the knee joint were very much con- 
tracted, relief was obtained from the use of liniment made with 
the oil of cajeput, freely rubbed on the part twice a day. 



424 DISEASES OF CHILDREN. 

From all the facts connected with the developement of the 
sequelae of scarlet fever, it is evident that more or less of in- 
flammatory action exists, and that depletion is the most proper 
remedy as a preventive, either during the existence of the pa- 
thognomonic symptoms of the disease, or when convalescence 
is marked by restlessness, dryness, and heat of the surface. 

RUBEOLA.-MEASLES. 

The first who described measles was Rhazes, although he 
does not speak of it as a new disease. It appears to have been 
confounded with small-pox. as he takes some pains to distinguish 
between them, and observes that the inflammation of the whole 
body, the inquietude and general distress during the febrile 
stage, are much greater than in variola, although all the early 
writers have maintained an affinity between the two diseases.* 
Willan has endeavoured to prove that it was known to the 
Greeks and Romans ;f but there are some doubts in relation to 
this fact, and also with reference to its appearance in Europe 
before the fifth century. 

The first accounts we have of measles in America is about 
the year 1518, when it was imported from Europe. J No re- 
cords exist of its prevalence in North America until 1713 ; since 
that time it has occasionally spread through different sections 
of the country, and often with great severity. 

Etiology. — In by far the greatest number of instances 
measles occurs in young children, and even infants at the time of 
birth have been seen with the traces of the eruption. It is one 
of the peculiarities of all eruptive fevers, that the first period 
of life is the time when they make their invasion; and the 
exceptions to this law are so few in number, as to be of little 
account in affecting its universal application. Measles more 
frequently attacks children after the period of dentition than 
before. 

It arises from some specific cause, of a nature unknown, 
and usually shows itself as an epidemic, during the cold and 
changeable weather at the close of the winter. Although 
generally appearing at this season, yet there are cases con- 
stantly to be found throughout every part of the year. It is 
communicable by infection or contagion, and has been trans- 
mitted by inoculation with the blood of those affected with it, 
and also with the tears and saliva.]] Dr. Dewees, however, 



* The Medical Works of Dr. Richard Mead, vol. iii. p. 151 ; London, 1763. 

t Miscell. Works; London, 1821. 

$ D'Anhiera de Rebus Oceanicus, etc. Quoted bv Rayer. 

U Gentlemen's Mag., 1766, p. 187. 



EXCERNENT SYSTEM. 425 

states, that attempts were made in the Philadelphia Dispensary 
to produce the disease by inoculation, in the year 1801, with the 
blood, tears, and the secretions from the nasal and bronchial mem- 
branes, and also with the exfoliated epidermis, without effect.* 
On the authority of the late Colonel Green, it is confidently 
stated that his relative, Dr. Green, of Greenwich, R. L, inocu- 
lated, in the year 1799, three young persons in his circle, with 
blood taken from the eruptive surface of a patient labouring 
under an aggravated form of measles ; and that these cases of 
inoculation were entirely successful, so that the distinctive 
characters were recognised by all who saw them. 

This disease appears to be easily transmitted, when once it 
occurs, and it is not often that many children in the same house 
escape it, when exposed to the influence of the contagion. It 
is not, however, so easily communicable as small-pox or scarlet 
fever. Some persons do not possess the predisposition for the 
developement of the affection; for repeated exposure, even in 
the same bed, has not been sufficient to produce it, while 
others similarly exposed were attacked ; yet the disease is so 
common, as to have induced the belief among some that there 
is, in all probability, no individual who remains throughout life 
insusceptible, although he may have been previously unaffected. 

In general it attacks a person but once; but to this there 
have been exceptions ; and there has not only been a second, 
but even a third attack.f The occurrence of a second invasion is 
so rare, that Rosen, during forty years experience, never knew 
of one. J Willan never saw a second instance of measles in 
the same person. Eberle has seen but one. || Rayer mentions 
the occurrence of the disease a second time in three instances ; 
and also mentions the fact of Genovesi and Duboscq having 
prescribed for several persons, children as well as adults ; among 
the former, as many as forty-six in one epidemic, who had before 
passed through the disease. § 

It appears to be variously modified, according to the peculiar 
constitution of the atmosphere; for different degrees and forms 
of this disease have been described at different times. Hence 
a variety of names has been given to the various modifica- 
tions, according to the atmospheric influence, and the effect of 
different idiosyncracies. The former exerts a marked influence 
on the character of the disease ; it being more aggravated 
during cold and changeable weather, with much greater in- 
flammatory symptoms, or severe pulmonary congestion, than at 
other times. 

* Dewees, Op. Cit., p. 417. t Quoted by Burserius, vol. ii. p. 446, 
t Burserius, vol. ii. p. 446. II Op. Cit., p. 429. 

§ Rayer, p. 143. 
54 



426 DISEASES OF CHILDREN. 

Morton regarded the mild form as a sporadic disease, 
while the severe and malignant arose from epidemic causes. 
This, however, is not the case ; for the most benignant kind has, 
as is frequently seen, prevailed as an epidemic. 

Semeiology. — The common measles, or the disease in its 
most simple and uncomplicated form, begins with the ordinary 
symptoms of febrile affections, with the additional signs of 
slight inflammation in the respiratory passages, more particu- 
larly in the nares. On the invasion of the disease, therefore, 
there are alternate feelings of chilliness and heat ; and on the 
second day, an increase of the febrile- symptoms, occasionally 
very severe, with great thirst, a white tongue, and a remarkably 
free secretion of thin mucus from the nostrils, attended with 
sneezing. The eyes are also red, and the tears flow freely. 
There is also a sensation of weight in the epigastric region. 
Cough usually shows itself at this period of the disease, but is 
not severe. A great drowsiness not unfrequently attends the 
other symptoms, and in young children some slight convulsions 
will appear. All these symptoms are increased on the third 
day ; the eyes become acutely insensible to the light ; the cough 
is dry and hoarse, great determination takes place to the brain, 
which in teething children is often relieved by a free diarrhoea. 
In older children there is delirium, with starting in the sleep, 
high excitement, hard and frequent pulse, and a hot skin. 

On the fourth day the eruption appears on the face, in the form 
of small red spots, resembling flea bites, particularly around 
the mouth, on the cheeks, and forehead. It spreads successively 
on the neck, chest and limbs, within twenty-four hours after its 
first appearance on the face, and is attended with great itching 
and heat. These spots enlarge, unite, and form clusters, having 
a semicircular shape, the skin in the interstices being of the 
natural hue. During the height of the eruption, an elevation 
of the affected part may be distinctly felt, particularly on the 
face, which in severe cases is considerably tumefied. About 
the same time, spots of a dull red colour show themselves on 
the uvula, velum, gums, and other parts of the buccal membrane ; 
while a sense of dryness and huskiness is felt by the patient in 
the throat. On the following day the eruption appears to be 
nearly confluent, and is completely developed on the face ; w T hile 
the constitutional symptoms continue without abatement until 
the eruption begins to decline, when they likewise decline, and 
the local affections of the eyes, throat and nares, also disappear. 
In light cases the symptoms of pulmonary inflammation also 
disappear ; but in many instances the cough and sense of op- 
pression in the chest remain after the eruption has disappeared, 
and will continue for some time during convalescence. 



EXCERNENT SYSTEM. 427 

This fading of the eruption commences about the sixth or 
seventh day from the invasion, in the same order it observed in 
its appearance, commencing at the face ; it changes to a yel- 
lowish colour. The epidermis becomes detached in a scurf, 
and a troublesome itching continues over the skin, which re- 
mains dry and rough. At this period of the disease it not un- 
frequently happens that the coma returns in young children ; it 
does not, however, appear to be attended with danger. The 
occurrence of diarrhoea at this stage is not unfrequently noticed, 
and appears to be critical, particularly in teething children. 

Such is the course of ordinary measles ; but different modifi- 
cations of it have appeared, either from the action of a more 
than usual malignancy in the exciting cause, or from the effect 
produced by a peculiar idiosyncracy and the excess of inflam- 
matory action, or the existence of local congestion in important 
organs. The earlier or later appearance of the eruption of 
itself does not interrupt the regular course of the disease. It 
has sometimes not shown itself until the seventh day, and then 
passed regularly through its stages. 

The disease at times presents other symptoms, marking a 
greater or less degree of departure from the regular course 
above mentioned. Thus the imperfect form, or that in which 
there exist no catarrhal symptoms, but the cutaneous eruption 
observing its regular course without anv febrile excitement, 
is at times noticed amidst the disease in its most inflammatory 
form. This does not appear sufficient to protect the system 
against the contagion, for, after an indefinite period, according 
to Willan, the developement of the ordinary measles has oc- 
curred. 

On the contrary, another form of the disease has been de- 
scribed by Gregory and Guersent, where all the symptoms of 
measles, except the eruption, appeared in the midst of an 
epidemic. This is the morbillious fever of some authors. 
Sydenham describes a fever of this kind, which was marked 
with no other eruption than patches on the shoulders, which 
never appeared in any other part of the body. 

Another, and the most common occurrence in measles, when 
severe, is the excess of the local inflammatory symptoms. 
There is then great pain in the head, and sometimes delirium, 
severe cough, with pain in the chest on respiration ; the accom- 
panying fever is severe, pulse hard and quick ; and, in short, the 
usual signs of local inflammation, of greater or less severity, 
manifest themselves from the commencement of the initiatory 
fever. 

The black measles, Rubeola nigra, of Willan, is a very rare 
disease ; indeed, I do not know that it has occurred, as de- 
scribed bv him, in the United States. Livid and dark-coloured 



428 DISEASES OP CHILDREN. 

eruptions appear in some severe cases of the disease, when 
attended with great congestion about the lungs ; but this is not 
the kind described by Willan, which is marked by a change in 
the eruption on the seventh and eighth day from the invasion, 
to a dark, livid colour, mixed with a shade of yellow. This 
appearance occurs in persons of a debilitated constitution, or 
who have been exhausted by severe diarrhoea. It has also 
been remarked in those who have been affected with tubercles 
in the lungs. 

Measles, with typhoid symptoms, will at times appear among 
the children of the poor, who suffer from want of proper food, 
and from the air of their confined habitations. It is like that just 
mentioned, of very rare occurrence. It is attended with colli- 
quative diarrhoea, hemorrhages, and, on its invasion, with a re- 
markably pungent heat of the skin, like the worst forms of scarlet 
fever, which in some of its symptoms it closely resembles. 

This disease may be complicated with other inflammatory 
affections than those of the lungs and bronchise, above mentioned. 
Severe attacks of croup have taken place during the pro- 
gress of the disease ; and an active inflammation of the meninges, 
brain, of the eyes, and gastro-intestinal membrane, at all times 
complicate the disease, and render it more or less difficult of 
management. The latter especially demands close attention, 
from the influence it exercises on the proper developement and 
progress of the pathognomonic symptoms of measles. 

When complicated with gastro-intestinal inflammation, the 
disease is attended with much pain in the head, a dark fur appears 
on the tongue, and there exist considerable tenderness and full- 
ness of the epigastrium. In this complication there is more obsti- 
nacy in the vomiting, which attends at times the commencement 
of the disease ; and when purging occurs simultaneously with the 
appearance of the eruption, or at the period when it is expected 
to show itself, the latter is imperfectly developed, being pale 
and irregular, both in appearance and extent. The irritating 
and incessant cough, and difficulty of respiration, also attend 
this form, but destitute of the ordinary marks of active pul- 
monary inflammation. This complication of gastric inflamma- 
tion is, next to the typhoid and congestive kind, the most obsti- 
nate, while it is the most common of the complicated varieties 
of measles. 

When the disease attacks, by producing a congestion of some 
of the internal organs, no reaction takes place, or it is very im- 
perfect. The surface is pale, with a livid appearance of the 
lips, and a sunken expression of the face. Sometimes patches 
of a bluish colour appear on different parts of the body. The 
congestion occurs in most instances about the lungs, and a state 
of coma, or an attack of convulsions, takes place very quickly 



EXCERNENT SYSTEM. 429 

after the invasion of the disease. Young children of a delicate 
habit are very easily overpowered by the contagion ; and con- 
gestion, from the rapid exhaustion of vital power, very quickly 
ensues. Convulsions, also, often occur, especially in young 
and teething children, on the invasion of the disease, without 
any other premonition. 

The consecutive effects of measles are, chronic bronchial 
inflammation, inflammation of the eyelids, chronic enlargements 
of some of the lymphatic glands, pustular eruptions over the 
limbs, back and groins. Chronic bronchial affections, and of 
the pulmonary mucous membrane generally, with an obstinate 
and long continued cough and huskiness of voice, are the most 
common sequelae of measles. Phthisis, also, is often developed 
by an attack of this disorder. These pulmonary affections are 
extremely liable to occur afresh, on the slightest exposure to 
cold and damp, for a long time after a severe attack. 

The nature of the disease may be suspected during the ini- 
tiatory fever, by the redness of the eyes, the flow of tears, 
sneezing, and a flow of thin mucus from the nose. There is at 
the same time a distressing dry cough, when these symptoms 
show themselves in those who have not before had measles. 
When it is prevailing, there can scarcely exist a doubt as to 
the nature of these symptoms. The eruption shows itself in mi- 
nute elevated spots, so closely resembling those of small-pox or 
varioloid, as not to be at first distinguishable from them ; but 
they very soon coalesce, and exhibit the appearance of stains. 

The disease with which it is most apt to be confounded, is 
scarlet fever. In the last mentioned affection, the colour of the 
skin is more continuous, does not exhibit a clustered form, with 
intervals of a healthy colour, with semi-lunar edges. On the 
first appearance of the rash in measles, small red points show 
themselves, which unite at their edges, are less highly coloured, 
and impart a kind of spotted appearance to the skin ; while in 
the scarlet fever the redness is more diffuse and uniform, with- 
out the maculated appearance of the other. In measles the erup- 
tion usually appears on the fourth day ; in scarlet fever, on the 
second. 

When simple, and uncomplicated with local inflammation, 
measles is not a disease of danger, and the prognosis, with or- 
dinary care, may in general be favourable. Any irregularity 
in the appearance of the eruption, as its retrocession from 
whatever cause, must be regarded as affording an unfavourable 
prognosis. So, also, the appearance of patechise, or hemor- 
rhage, connected with the eruption, is to be regarded as indi- 
cating great danger. Congestion and inflammation about the 
lungs, more especially in young infants, are highly dangerous 
symptoms, particularly in those of a delicate constitution. 



430 DISEASES OP CHILDREN. 

Morbid Anatomy and Pathology. — Recent investigations 
show, that the seat of the eruption is in the reticular tissue of 
the skin and the pulmonary mucous membrane ; these parts 
being found injected after death. Inflammation of the mem- 
brane covering the bronchise and intestines, and the usual 
morbid secretions that are found on these inflamed surfaces, 
are all the changes discovered in fatal cases of inflammatory 
measles. In complicated cases more extensive lesions are dis- 
covered, according to the parts implicated, but more especially 
a loaded state of the lungs and their capillaries in severe con- 
gestive cases. In those less strongly marked by inflammatory 
symptoms, no changes whatever can be found on dissection. 

The nature of measles is essentially inflammatory, as the 
symptoms and post-mortem examinations show. It has, how- 
ever, prevailed at times with highly malignant symptoms, cha- 
racterized by a great prostration of strength, and a congestion 
about the lungs. This loss of energy in the larger vessels pro- 
duces the feebleness in the capillary circulation, which may 
arise from the action of the contagious principle, or from debi- 
lity in the child, whereby reaction is imperfectly established. 
This is more frequently found to be the case among the chil- 
dren of the poor, who suffer from bad food and impure air. 
The effect of overheated stove rooms is to increase the tendency 
to excessive congestion of the lungs, and to impart an appear- 
ance of malignancy to the disease. In the latter part of the 
seventeenth and the beginning of the eighteenth centuries, mea- 
sles appears to have been particularly marked by congestive 
and malignant symptoms, which have been described as a putrid 
form by Huxham and Morton. The epidemic measles of Lon- 
don, which prevailed about the year 1765, is described by Dr. 
Watson as of a similar nature. All these cases are more pro- 
bably congestive and irregular forms, arising from a feeble re- 
action in the system, producing both an accumulation of blood 
in the centre of the circulation, and from the effect of imper- 
fectly purified blood in the lungs, imparting to inflammation of 
the skin and mucous membrane an erysipelatous and gangre- 
nous tendency. Where the rash has receded, and great debility 
ensued, with oppressed breathing and anxiety, this congested 
condition evidently exists, as is proved by dissection. 

Treatment. — This disease, like other eruptive fevers, observes 
a regular course, with a natural tendency to a healthy termina- 
tion. The treatment, therefore, in the mild variety, ought to be 
of the simplest character, as the adoption of active measures 
will but disturb the disease in its proper course ; and in debili- 
tated subjects even the powerful action of a purgative is at- 
tended with hazard, by causing an excessive irritation, and a 
transfer of the capillary action from the parts where nature has 



EXCERNENT SYSTEM. 431 

seated it, to the more dangerous location, the gastro-intestinal 
mucous membrance. 

Where the disease is unattended with much pulmonary dis- 
order, it is scarcely necessary to prescribe any thing more than 
the mildest aperient, followed by warm diluents, as barley wa- 
ter, lemonade, or linseed tea ; while the patient is kept in a 
moderately warm temperature. The feet may also be bathed 
with warm water, to preserve a proper action on the surface, and 
prevent an undue determination of blood to the lungs. 

When the febrile symptoms are active, it will be necessary 
to have recourse to diaphoretics and expectorants. Syrup of 
ipecacuanha is an excellent medicine for this purpose for infants, 
and may be given in the following combination.* It may also 
be prescribed alone, while its diaphoretic effects are promoted 
by the use of warm drinks. For older children, of a robust 
habit of body, small doses of antimony may be used. This, how- 
ever, is a medicine requiring great caution in young children, 
from the extreme exhaustion it is apt to produce. Its action is 
best promoted by combining it with acetate of ammonia and 
spirits of nitre. f Any of the expectorant and diaphoretic 
mixtures under the head of pneumonia or bronchitis may be 
used in this disease, the prominent symptom of which, that needs 
the interference of art, differing but little from the ordinary in- 
flammation of the air-passages of the lungs. With such a course 
of treatment, the greatest number of cases of ordinary measles 
will pass through their different stages with safety. 

It is not necessary, whenever there are oppressed breathing 
and a laborious pulse, during the formation of an eruptive 
fever, to resort to blood-letting ; for, as Dr. Willan observes, 
these symptoms are common to all fevers of this kind, and 
usually disappear on the appearance of the eruption. But 
when the fever and laborious respiration are accompanied' with 
pain in the chest, the usual symptom of inflammation, it then 
becomes necessary to resort to general blood-letting for its 
relief, if the general condition of the patient do not forbid 
its employment. 

When inflammation of the lungs exists, blood-letting must 
be our main resource, as upon the removal of the inflammation 
will depend the prevention of those serious and sometimes 



* Ifc Syrup Ipecac, gss. t Ik Liquor. Amon. Acetat., gv. 



Tolu, §ss. 
Aquae Glycyriz., §ij. M. 
A teaspoonful every two hours to an 
infant. 



Spts. Nit. D., 5ij. 
Vin. Antim., 3iss. 
Syrup. Simpl., gij- M. 
A dessert spoonful for a child three or 
four years old. 



432 DISEASES OP CHILDREN. 

fatal consequences which occur from uncontrolled inflamma 
tion of these organs. 

It has been the remark of most practical men, that children 
bear blood-letting in measles better than in any other disease ; 
and it is more particularly useful on the third day of the erup- 
tion, if the dyspnoea and cough continue, and especially if the 
breathing or cough be attended with pain. The overloaded 
state of the lungs, also, by impeding the circulation in the brain, 
disposes the child to convulsions, which cannot be better pre- 
vented than by blood-letting. At this period, also, the same 
objection does not exist to the employment of active measures, 
as in the forming stage of the disease ; reaction having become 
fully established, and the specific action of the disease having 
become decidedly inflammatory. 

The foundation of phthisis is often laid in an attack of mea- 
sles. Every precaution, therefore, should be used to control 
the exciting cause of this disease. When, therefore, there is 
much arterial action, with unequivocal evidences of inflamma- 
tion, bleeding is imperiously demanded ; and should be em- 
ployed by opening a vein in the arm, if the condition of the 
patient will admit of thus abstracting blood. Where there 
exists any doubt as to the propriety of general blood-letting, 
from any peculiarity of constitution, or from some complication 
of the disease, local blood-letting must be substituted, either by 
leeches, or cupping on the chest or between the shoulders. 

Whenever there is a local determination of blood to any 
of the viscera, producing an inflammation of important organs, 
prompt bleeding becomes our chief resource ; the complication 
rendering the disease far more hazardous than what would 
arise from an interference with the regular progress of the 
eruptive fever. Where the excess of inflammation is in the 
lungs, it will not probably be so promptly relieved by bleeding 
as ordinary pulmonary inflammation, or as in a complication of 
the other organs with measles, as that of the brain ; for the 
morbillious inflammatory affection of the lungs has a determi- 
nate course, and the object of the physician must be to mode- 
rate and control in some degree the inflammation, and thus 
prevent any injury to the lungs or bronchial membrane, or the 
deposition of tuberculous matter from the excited and deranged 
action of the part. 

One of the most common causes of an excess of pulmonary 
inflammation in the lungs in this disease, is an imperfectly 
ventilated apartment, or a too high or too low degree of tem- 
perature. The former is much more apt to occur, producing, 
besides a congestive state of the lungs, a high degree of fever, 
and great restlessness. The apartment, if possible, should be 
large, and the temperature not less than 60°, nor more than 70°. 



EXCERNENT SYSTEM. 433 

Where the cough and pulmonary difficulty remain unabated, 
and the arterial action has become moderated, blisters will 
generally be found useful ; and I think I have found them more 
beneficial in the slight remains of pulmonary inflammation of 
measles, than in the common inflammation of the lungs. They 
should be applied with the same caution in infants, bearing in 
mind that the action of a blister in this disease is much quicker 
than when there exists no inflammation of the skin. 

An inflammatory form of measles existed in the year 1828, 
in Paris, which, although in almost every form was complicated 
with inflammation of important viscera, and more especially 
of the lungs, yet would not admit of sanguineous depletion. In 
such cases blisters would be of important service ; and Dr. 
Eberle is of opinion that calomel and opium would be the most 
proper treatment in such cases.* 

One of the most distressing things in measles is the continued 
harrassing cough, which should, in the active stage only, be 
treated by the expectorants already mentioned, and the adoption' 
of a general antiphlogistic course. When, however, the in- 
flammatory symptoms have been in some degree controlled, 
and the cough continues, great relief will be experienced from 
the use of an anodyne, which will also greatly relieve the 
extreme restlessness arising from the cutaneous irritation. It 
may be composed of morphine, combined with the syrup of 
squills. f When there is much accumulation of mucus in the 
air-passages, great relief will be found from the use of gentle 
emetics. 

It not unfrequently happens that great irritation and inflam- 
mation of the gastro-intestinal mucous membrane occur in the 
course of the disease. This condition is usually attended with 
a quick pulse and loss of strength, followed by diarrhoea. 
When first noticed it is more easily relieved by bleeding, warm 
bath, and a freer use of demulcent remedies. All irritating sub- 
stances should be withheld, especially antimonials and purga- 
tives. The latter, especially, only aggravate the existing diffi- 
culty and greatly prostrate the patient. Great benefit will be 
derived from the application of a soft poultice, sprinkled with 
powdered camphor, applied over the abdomen. While these 
measures are used, the irritation of the affected part may be 
calmed with small doses of laudanum, administered by the 



* Op. Git., p. 441. 

t fy Syrup. Scillee, 3ij. 
Aquae, 3vi. 

Morph. Acet., gr. ss. M. 
A teaspoonful two or three times a day, for a child of six years of age. 

55 



434 DISEASES OF CHILDREN. 

mouth ; or if the irritation exist in the lower portion of the in- 
testines, producing symptoms of dysentery, a complication 
sometimes noticed, it may be given in an enema of starch or in- 
fusion of linseed. 

Tn every congestive form of measles it will be advisable to 
have recourse to gentle blood-letting by means of leeches, care- 
fully watching their effects, and if the pulse flags, to excite the 
energies of the circulation by mild stimulants, both externally 
and internally used. In the loaded state of the lungs, it will be 
useless to attempt the establishment of the arterial action with- 
out unloading the larger vessels, and thereby giving them an 
opportunity to act, while at the same time the great loss of vital 
power forbids the free abstraction of blood ; a medium must 
be carefully observed. So, also, cerebral congestion will some- 
times ensue, and the system will not react; but the skin con- 
tinues pale, and the pulse feeble and languid. The eruption, 
also, after it has made its appearance, will sometimes recede, 
'and leave the surface of the body in the same condition. The 
smaller vessels appear, under these circumstances, to have lost 
their power ; it will therefore be necessary to employ power- 
ful stimulants to the surface of the body, that they may be 
brought into action. A warm bath of salt-water, flannels wrung 
out in hot whiskey, frictions with capsicum, or mustard cata- 
plasms may be applied to the epigastric region and to different 
parts of the body ; and, in short, the measures recommended for 
treating congestive scarlet fever may be used in this form of 
measles. 

There is much more hope of succeeding with these measures, 
where the rash has receded after it has once made its appear- 
ance, than where no reaction has occurred. It is more often 
the case, also, that the child will bear bleeding, either locally or 
generally, better, when this congestive condition occurs at the 
commencement of the disease, than where it arises during its 
progress. The former, it would appear, often needs but little 
more than an unloading of the blood-vessels, perhaps to a small 
extent, in addition to the other means already mentioned ; but 
in the latter there is the necessary derangement of all the vital 
functions, attendant on a continuance of the diseased action, 
with perhaps the existence of local inflammation, which has 
been lighted up during its progress. This complication of dis- 
ease imparts to it therefore a character, which too often ren- 
ders it unmanageable. 

In some epidemics a loss of energy in the system marks the 
disease, producing the malignant or typhoid form, in which it 
is said that the most active stimulants are needed. Dr. Watson 
describes the epidemic measles at Edinburgh, in 1816, to have 



EXCERNENT SYSTEM. 435 

been of this character.* It was accompanied with great swell- 
ing of the face and eyelids ; and the eruptive stage was attended 
with symptoms of great severity, as coma and delirium. The 
fauces were deep red, as in scarlatina, and the eruption tardy 
and imperfect, and very irregular in its duration. Its appear- 
ance was sometimes red, pale, livid or dark, with a general 
prostration of the powers of the system. Such cases, it may 
be expected, would occur where there was great poverty, with 
badly ventilated habitations. According to the experience of 
the practitioners in this epidemic, bleeding was attended with 
hazard ; and stimulants, such as wine, cordials, and aromatics, 
were required. There can be no question but the mode of life 
greatly modifies the nature of diseases of this kind, for measles 
having typhoid symptoms has been noticed among individuals 
previously broken down by other diseases ; here it is obvious, 
depletion must be attended with hazard. Dr. Watson remarks, 
with reference to the epidemic above mentioned, that the pa- 
tients lost more by the bleeding than was gained by the relief 
given to the pulmonary affection. The treatment of such cases 
probably would be best managed by a judicious combination 
of small local bleedings and mild diffusible stimulants. 

From the tendency which exists during convalescence to in- 
flammatory action in the bronchial membrane, great care must 
be taken, by preserving the bowels soluble and keeping the pa- 
tient from the influence of cold, to prevent any permanent affec- 
tion in these important parts. The diet should be for some 
time rather of an abstemious nature, if there continue to be 
bronchial irritation, and other evidences of the remains of inflam- 
matory action. The clothing ought also to be sufficiently warm 
to preserve a due action in the cutaneous system. Tonics du- 
ring convalescence should in general be avoided, on account of 
the tendency to inflammation. When any difficulty of breath- 
ing, or pain in the chest arises, blood may with safety be drawn 
from the arm, or a few leeches may be applied over the in- 
flamed part, the feet immersed in a warm bath, and a sudorific 
anodyne administered at night. 

During convalescence it is not unusual for a diarrhoea to arise, 
and, when moderate, it assists much in relieving the inflammation 
in the larynx and lungs, so common after an attack of measles. 
It may for the most part be left unchecked, but when excessive, 
should be arrested by Dover's powder and absorbent medi- 
cines. The frequency of this diarrhoea has induced some prac- 
titioners to attempt to imitate the process of nature, by the 
administration of mild purgatives. 

* Edinburgh Medical and Surgical Journal, 1S17. 



436 DISEASES OF CHILDREN. 

For chronic bronchial affections, which continue, notwith- 
standing the remedies above mentioned, for some time beyond 
the ordinary period of convalescence, blisters on the chest, and 
rubefacients over different parts of the limbs, will always be 
found useful. 

VARIOLA.— SMALL-POX. 

It has been a subject of no little controversy, whether or not 
small-pox was known to the Greeks and Romans. Dr. Good in- 
clines to the opinion, that there exists no substantial reason for be- 
lieving that it was, and that there is no evidence of its existence 
in the Mosaic era ; in which idea he is supported by the opinions 
of Drs. Friend, Mead and Gregory. The other side of the 
question has the able names of Rhazes, Avicenna, Salmatius, 
and more recently, of Willan and Baron, of England. 

Although it is difficult to ascertain the period of its first ap- 
pearance in different countries, yet there is every reason for 
believing that this disease has been known and described in 
different ages and countries, from the earliest period of which 
we have any historical record. The disease probably existed 
at a much earlier period than is usually believed.* It was in 
China long before it was known in Europe ; and the earliest his- 
tory, the Bible, contains the account of an eruptive disease, 
which, in the opinion of some judicious critics, bears all the 
characteristics of small-pox. Dr. Baron is of opinion that it pre- 
vailed nearly fifteen hundred years before the Christian era, 
according to the commentary of Philo, a learned Jew, on the 
passage of Exodus, describing the boils and blains of Egypt. 
This account of the disease is a remarkable description of small- 
pox. This period also accords with the traditions of the Chi- 
nese and Hindoos, as to the time when it first appeared. The 
disease of Job, it has been supposed, was the small-pox ;f and, 
although it has been found a subject of extreme difficulty to 
settle the point of the time in which he lived, yet, according to 
the system of chronology of Usher, it could not have been far 
from that already mentioned as being the period when the 
Egyptians were affected with the blains and boils. 

The first distinct account, according to Mead, of the disease 
having been traced from one country to another, is that of its 
conveyance in a vessel from China to Arabia, in the sixth cen- 
tury, whence it was introduced into Europe through Africa, by 
the Moorish army ; Sicily and Spain being the places where it 
first appeared. 

* V. Dr. Baron's Life of Jenner. 

t Medka Sacra, by Thomas Shapter, M. D. 






EXCERNENT SYSTEM. 437 

The precise time of its introduction into Great Britain is un- 
certain, but it appears to have been common there about the 
end of the twelfth century ; and it is well known, that within 
the last two, it has been one of the most dreaded scourges that 
ever visited that land, until the discovery of the immortal Jen- 
ner deprived it of its terrors. 

The earliest account we have of the existence of small-pox 
in America, is its prevalence among the Indians in the year 
1633,* no doubt introduced among them by the first visits of 
the Colonists. In 1638, a general fast was observed through- 
out America, among other reasons, on account of the " small- 
pox and other fevers."! Since that time, historical records 
abound with statements of its frequent prevalence in every part 
of the continent. 

Etiology. — The cause of small-pox is a specific animal 
poison. It will operate through the atmosphere, and follow 
the direction of the wind, the air being loaded with the infec- 
tious principle ; the disease, therefore, is communicable as 
well by respiration, as by the contact of clothing, bedding, etc., 
of the sick, and by the direct introduction of the matter from 
the pustules. This fact is proved by many instances, occurring 
on a simple exposure to the atmosphere of an apartment where 
a patient is ill with small-pox, without any contact with the 
affected person, or with his clothes. 

The contagion, like that of other similar diseases, is much 
modified by an unknown principle in the atmosphere, whereby it 
has at times spread rapidly as an epidemic, sparing neither age 
nor any condition of life. When thus prevailing, it was ob- 
served to be more fatal in the heat of summer and cold of winter, 
than either in the spring or autumn. The constitution of the air, 
also, modifies it in such a manner as to render it at times, 
although prevailing as an epidemic, milder and less complica- 
ted than at others. The surrounding circumstances have a 
great influence in modifying the disease : thus, in confined places, 
especially in the basement of a house, it is more frequently con- 
fluent than in the higher parts of the same house. In the garrets, 
especially where the streets are wide and well-aired, it is often 
distinct, and generally more mild. Heat also greatly modifies 
the type of this disease. In a child kept hot during the eruptive 
fever, it is apt to become confluent, while another kept cool, 
will most likely have the distinct form.J 



* A Journ. of the Transact, and Occurrences in the Settlement of N. E. ; by John 
Winthrop, Esq.; Hartford, 1790, p. 56. 
+ Webster's History of Pestilential Diseases, vol. i. p. 185. 
t Armstrong, p. 480. 



438 DISEASES OF CHILDREN. 

It is also greatly under the influence of the peculiar pre- 
disposition of the individual ; some having the disease with 
scarcely any thing more than a slight fever, and a trifling erup- 
tion, and passing regularly through its different stages ; while 
others suffer with it in its most confluent form, with severe and 
protracted fever. If the patient be in ill health at the time of 
the attack, it will be more severe. 

Although all are liable to be attacked with small-pox, yet it 
generally affects children and young people. Some persons, 
however, who have escaped in early life, have in old age be- 
come the subjects of this disease. Others, again, have remained 
through life entirely exempt from it. In general the predis- 
position to receive the disease is destroyed, when once the in- 
dividual has passed through an attack. To this, however, there 
have been many exceptions. 

The foetus has been affected with the disease, as appears 
from the existence of small-pox pustules at birth, in numerous 
instances, recorded by Drs. Mead, Jenner, Laird, Forbes, Ho- 
sack, and others.* This has not only occurred where the 
mother was simultaneously affected, but where the mother 
presented at the time no trace, nor any indication whatever of 
an eruption. Such instances have been recorded by Mauri- 
ceau, Mead, Watson, Forbes, and several others. 

The disease also has been caused by inoculation with the 
matter taken from the pustules, when it has been observed to 
produce a much milder affection than when taken in the ordi- 
nary course of nature. This fact early led to the practice of 
inducing the disease artificially ; a practice which has been 
traced to the remotest period of which we have any account 
of the existence of the disease. It was common in China, India 
and other parts of the Eastern World, where the small-pox first 
existed. It was also used in Africa before its adoption either 
in Great Britain or America, f In the year 1721, it was intro- 
duced into England by Lady Mary Wortley Montague, from 
Constantinople, where it had been in use for nearly a century. 
In the early part of the same year it was also introduced into 
Boston, by the Rev. Cotton Mather, who had read some occa- 
sional account of its practice in the East. In the extension 
of this prophylactic measure he was aided by Dr. Boylston, and 



* A Dissertation on the Pathology of the Human Fluids, by Jacob Dyckman, 
M. D. ; New-York, 1814. 

t The Rev. Increase Mather published " Several reasons for proving that ino- 
culating or transferring small-pox is a lawful practice." Among others which 
he adduces, are the direct benefits derived from it* and refers to the fact, that " we 
have an army of Africans among ourselves, who have themselves been under it, 
and given us all the assurance which a rational mind can desire, that it has been 
used with the like success in Africa." — Mass. Hist. Collect, vol. ix. p. 278. 






* EXCERNENT SYSTEM. 439 

three hundred persons were inoculated early in that year.* It 
made considerable progress in New-England before it was fully 
adopted in Great Britain. 

The following account of this important transaction is from 
the Philosophical Transactions for the year 1723. "In May, 
1721, the small pox was brought into the town of Boston; in 
June it began to spread very much ; and in the month of July 
it had got into most parts of the town, and a considerable num- 
ber of people died of it. At this time inoculation was first 
practised by Dr. Boylston, who performed it on his own child 
and a negro servant, who both did well ; notwithstanding which, 
this attempt gave great uneasiness to the neighbours." 

Although opposition to it existed to a great extent, yet there 
was much less than in England, and it was soon practised by 
most of the physicians of New-England. f Among the most 
strenuous advocates for this practice wasDr.NathanielWilliams, 
who lived at Boston during the prevalence of the epidemic 
above mentioned: he died in 1737, leaving manuscript direc- 
tions for the proper performance of inoculation, which were 
afterwards published.J 

Semeiology. — Small-pox is usually divided into two forms ; 
that in which the eruption is distinct, being but the milder va- 
riety of the disease, and that wherein it is confluent ; differing 
from the other principally in the severity of the symptoms, and 
the greater number and size of the pustules. 

The course of small-pox, through its different stages, may be 
divided into four periods, which will include every form the 
disease assumes, from the time of the reception of the poison 
to that of the desiccation or decline. The first is the period of 
incubation; the second that of fever; the third that of matura- 
tion, including suppuration ; and the fourth that of desiccation. 

The period of incubation includes the time between the re- 
ception of the infection and the first appearance of the precur- 
sory fever. The time is very uncertain, for small-pox has in 
some instances appeared to attack the individual almost imme- 
diately on being exposed to the influence of the contagion. 
There would seem, however, to be in general a determinate 
period existing before the manifestation of the primary symp- 

* Philosoph. Transact., vol. vi. p. 616. 

t When first introduced into England, among other powerful opposers were 
some of the clergy, who publicly preached against the practice as highly sinful. 
The Rev. Mr. Massey preached at St. Andrews, Holborn, on the 8th of July, 
1722, from Job, ii. 7, against inoculation, as derived from the Devil, Satan being 
the first inoculator when he smote his victim with boils. 

t The Method of Practice in the Small-Pox, with Observations on the way of 
Inoculation, taken from the manuscript of Dr. Nathaniel Williams, of Boston, 
N. E.j Boston, 1732. 



440 DISEASES OF CHILDREN. 

toms. The difficulty, however, of ascertaining the fact, where 
there are no external signs of disease, renders it uncertain : it 
is supposed to be about the fourteenth day ; Boerhaave and Stahl 
make it about the sixteenth or seventeenth day. 

On the first appearance of the disease there are rigors, cephal- 
gia and lumbago ; the latter symptom, with a feeling of great 
debility, almost uniformly exists. In children, besides these 
symptoms, which are common to all ages, there will also exist 
a great drowsiness, with starting during sleep ; and inequality 
of circulation is more marked in them, and the extremities are 
generally cold. There are generally pain and tenderness of 
the stomach, and sometimes vomiting. Some are attacked with 
convulsions a few hours before the appearance of the pimples ; 
all are more or less agitated and easily terrified, especially on 
awakening from sleep. The fever is well marked, with great 
heat of the skin, and a deeply flushed face. In children there 
is a great dryness of the surface, in which respect they differ 
from adults, in whom there is often a free sweating, marked by 
a peculiar odour. 

These symptoms continue for three days ; and on the com- 
pletion of this period, or perhaps early on the fourth day, small 
red spots will be seen on the face and breast, marking the begin- 
ning of the second stage of the disease. These spots bear a 
strong resemblance to flea-bites, but quickly change their ap- 
pearance to small elevated pimples, enlarging both in width 
and elevation. These pimples gradually appear on different 
parts of the body, when there is usually a considerable abate- 
ment of the fever, nausea and local pain. The pulse and hur- 
ried respiration, also, abate much in frequency, while the skin 
becomes relaxed and moist. The eruption assumes this red 
papular form about the fourth day, having a rough and knotty 
feeling ; it continues to enlarge, and is of a deep red around the 
bases, while the summits appear a little whitish, from the secre- 
tion of a semi-transparent serum. A minute vesicle is thus 
formed on the summit of the pimple, slightly depressed in the 
centre. Various changes take place in the pustules, com- 
mencing with those of the face, on the fifth or sixth day. They 
are observed to become more extended, and surrounded with a 
red areola, while the serosity with which they are filled changes 
in colour and consistency, becoming yellower and thicker, hav- 
ing the appearance of pus. At this period the secondary fever 
arises, on the fifth day of the eruption, and continues through 
the whole period of suppuration; the face swells greatly; the 
eyelids are closed, and, in proportion to the progress of the 
pustules to maturation in other parts of the body, the tumefac- 
tion of the cellular membrane extends, becoming exceedingly 






EXCERNENT SYSTEM. 441 

painful and itching, especially that of the face and hands. The 
completion of the eruption is on the seventh or eighth day, 
when the pustules are about the size of a pea, occupying not 
only the skin, but the mucous membrane of the mouth and throat. 
On the last mentioned day the red ring begins to disappear, 
leaving the pustules white and opaque from the purulent fluid 
they contain. 

The period of desiccation commences about the eleventh 
day, when the swelling of the face begins to abate, and a small 
dark spot appears on the apex of the pustule. This dark spot, 
caused by the drying of a small quantity of purulent matter 
which has escaped, gradually extends, until the pustule is con- 
verted into a scab, which falls off about the fourteenth or 
fifteenth day. On the body, the separation of the scab is not 
until a day or two after ; while the pustules on the limbs, from 
the imperfect formation of the purulent matter, do not form 
perfect scabs, but dry scales, having more the appearance of 
thickened cuticle. The separation of these scabs and scales 
leaves depressions or pits where the former existed, and dis- 
coloured patches in other parts, on which the scales were formed. 
This is the ordinary course of the distinct and mild form. 
Where the disease is severe, and the pustules confluent, there 
is more irregularity in the symptoms, and many anomalies in 
its progress. 

The pustules, in the confluent or coherent variety, do not 
undergo the same regularity in their progress — there exist 
more inflammation, swelling and pain; and, from the great 
number of the pustules, and their running together, the name 
of confluent is given to this form of small-pox. 

The confluent form differs from the distinct or simple, princi- 
pally in the violence of the fever, indicating greater constitutional 
derangement ; in the greater number of the pimples, closely 
crowded together; their inflammatory nature, without perfect 
suppuration, and in the continuance of the, fever, with very 
slight or no remission on the appearance of the eruption. 

All the symptoms of fever which precede the eruption are 
aggravated in intensity, with greater evidences of congestion, 
than in the disease in its simple type. The oppression of 
the chest is greater ; there is often a short, dry cough, with a 
frequent and oppressed pulse. Symptoms, also, of a partial 
congestion of the brain show themselves in the great drowsi- 
ness and delirium ; convulsions also are liable to occur. 
There is also much greater manifestation of inflammation in 
the stomach and intestines, with greater and more continued 
nausea and vomiting. There is in every case of small-pox 
more or less difficulty of deglutition from swelling of the mucous 

56 



442 DISEASES OF CHILDREN. 

membrane of the throat. This symptom is much greater in 
confluent than in distinct small-pox. 

In this variety, also, the eruption shows itself earlier than in 
the other form, usually on the third day, or earlier, instead of 
the fourth; but in this respect there is no regularity, for it 
may be retarded until the fifth and sixth day. In generaj, the 
pustules do not exhibit the same perfection in maturation, but 
present a great difference in their appearance from that which is 
presented in the distinct form. 

The colour changes about the eighth day to a dusky brown, 
from the oozing of the fluid desiccating on the surface. These 
scabs separate about the twenty-first day in large scales, and 
leave the ulcerated surface beneath exposed to view ; these 
ulcerations, which are seated in the true skin, are the cause of 
the pits and seams, which mark the faces of those who have 
passed through a severe attack of small-pox. These are more 
marked about the face, where the confluence principally takes 
place. 

There is in children almost always a diarrhoea during the 
height of the disease, sometimes attended with bloody dis- 
charges, and always with much prostration. 

The fever does not abate on the appearance of the eruption, 
as is the case when the disease is mild and distinct, but all the 
symptoms increase in intensity and severity. From the im- 
perfection of the suppuration, the face becomes white or pale 
as the confluence takes place, and it has the appearance of a 
continuous elevation of the cuticle, beneath which is a thin 
serous fluid, instead of the yellow, thick pus, which marks the 
disease when passing regularly through its stages. 

The fever, which is renewed on the appearance of the scabs, 
and known by the name of secondary fever, is very severe 
and intractable ; the skin becomes dry and hot, the tongue dry, 
with great thirst. It is usually complicated with severe ner- 
vous symptoms, similar to those produced by the shock the 
nervous system receives from a severe and an extensive burn. 
Violent inflammation also occurs, either in the lungs, pleura, or 
some part of the abdomen. The eyes also suffer greatly from 
violent inflammation, which at times extends through all their 
tissues. Abscesses, petechias, and gangrene, occur in various 
glands and cavities. 

Such are the symptoms which small-pox exhibits in its true 
form, when unaffected by the peculiar conditions of the atmos- 
phere on the constitution of the body, or the effects of the partial 
immunity which the body receives, from having been affected 
with a previous attack of this, or of kindred diseases. This 
subject will be again considered at large, when treating of 
modified small-pox. 



EXCERNENT SYSTEM. 443 

Morbid Anatomy and Pathology. — The pustules of small- 
pox are found over the whole of the cutaneous surface, but 
much less in number on the extremities than on the face or 
trunk. They are also found in the margin of the eyelids, nos- 
trils, mouth, and palatine arch, and at the verge of the various 
passages to the internal parts of the body. The existence of 
variolous pustules in the oesophagus, stomach, intestinal tube, 
and other internal parts, has been denied by Haller, John 
Hunter, Tissot, Wrisberg, Riel, and others. Where pustules 
have been found in the stomach, duodenum, and other mucous 
surfaces, in fatal cases of this disease, they have been observed 
to present a different appearance from a genuine variolous 
pustule of the cutaneous surface, but by Cruveilhier regarded 
as variolous pustules. In the opinion of the above mentioned 
able pathologists, they are enlarged and ulcerated muciparous 
follicles. 

The brain presents but little morbid change, either in its 
substance or membranes, even in such as have been remarkable 
for coma, or who have been carried off in convulsions. But 
little effusion is found in any of the cavities. 

According to the dissections of Haller, Wrisberg, Riel, and 
others, the mucous membranes of the throat, larynx, trachea 
and bronchise, bear the greatest marks of disease, being re- 
markably distended with blood in the smallest branches of the 
blood-vessels ramifying over their surface. In every patient 
that dies of small-pox the inflammation extends throughout 
the mucous membrane of the air-passages to the extreme 
branches of the bronchiae. Besides these marks of inflamma- 
tion, there often exist viscid mucous and purulent matter 
effused over these mucous surfaces, sometimes tinged with 
blood. Ulceration, and a destruction of portions of the rima 
glottidis, and the parts adjacent, are also found in severe cases 
of small-pox. 

In violently malignant cases, besides marks of inflammation in 
the alimentary canal, which are by no means so frequent as in 
the air-passages, there are found petechia? and sphacelated spots. 

The villous coat is in some places abraded, leaving dark 
coloured eschars, especially in the small intestines. The 
muciparous glands also are enlarged and indurated, and are 
intermingled with the petechial spots above mentioned. In 
young children these alterations are of frequent occurrence, 
as would be expected from the diarrhoea so common in them. 
Sometimes the liver is found greatly congested. 

The action of the variolous contagion is therefore on the 
different tissues of the body, but affecting them in different ways. 
On the skin, it is manifested by the well-known circumscribed 



444 DISEASES OF CHILDREN. 

inflammation and pustular formations, varying in intensity in 
proportion to their number. This is also in direct proportion 
to the violence and extent of the internal inflammation. When 
the disease is confluent, the mucous membrane of the stomach 
and air-tubes, but more especially the latter, are very seriously 
affected with inflammation and ulceration ; and death is usually 
preceded by evidences of a very severe disorder of the pul- 
monary mucous membrane and Jungs. 

The mucous membranes, therefore, it is evident, undergo 
very serious morbid alterations, as well as the skin ; the more 
violently the disease manifests itself by its usual distinctive 
external signs, the more are the internal membranes disordered ; 
but they exhibit no appearances of pustular inflammation, 
although evidently affected by the variolous contagion. This 
is one among numerous other evidences existing, of the physio- 
logical connection between the external covering of the body 
and the mucous membranes. 

Treatment. — Notwithstanding the prophylactic measures for 
the treatment of small-pox within the reach of every one, yet, 
from ignorance or neglect, or from other causes, small-pox still 
exists as a serious scourge to portions of the human family, 
and the physician frequently has to encounter this most loath- 
some disease. It is therefore his duty to be prepared to meet 
it, according to the principles which experience has established 
for its proper management. 

From the great dread formerly entertained of the system 
being exposed to great danger from a tardy or imperfect ap- 
pearance of the eruption, every effort was made to excite the 
skin, that the morbific poison might be quickly thrown on the sur- 
face of the body. Hence, heating cordials, heated and close 
apartments, and a quantity of bed clothes with which the patient 
was kept covered, formed the principal part of the treatment of 
small-pox. To this course of practice, so assiduously per- 
severed in for a great length of time, must the vast amount of 
fatal cases be attributed, judging from the demonstrations fur- 
nished latterly by the opposite mode of management ; for the 
beneficial effects of the antiphlogistic method have been fully 
confirmed by experience. 

The treatment naturally divides itself into meeting the most 
prominent symptoms of each stage above mentioned. The first 
stage, that of incubation, will scarcely be expected to receive 
any other attention than the adoption of the ordinary rules of* 
hygiene, with the usual antiphlogistic course necessary to pre- 
pare the system for the invasion of fever. No certainty can 
exist as to the reception of the disease ; nothing, therefore, can 
be expected from the physician during this period. 



EXCERNENT SYSTEM. 445 

The second stage, or that of febrile developement, is an im- 
portant period for the treatment of this affection. It is difficult 
to ascertain satisfactorily that the fever is any other than the 
ordinary inflammatory fever ; it may, however, be strongly 
suspected to be the premonition of variola, when the epidemic 
is prevailing, and the disease is ushered in with more than or- 
dinary feeling of debility, especially a weariness in the loins. 
The indication in this stage is clearly to lessen the violence of 
the febrile excitement ; and the measures to be adopted for this 
purpose must be according to the violence of the excitement, 
and the circumstances of previous strength or debility of the 
individual, the condition and mode of life, etc. 

There has existed a difference of opinion as to the necessity 
of blood-letting in the opening stage of this disease ; some main- 
taining that it produces great debility, under which the system 
is apt to sink, when the extensive suppuration of the pustules 
takes place. Although the fever is high, and the pulse strong 
and full, this alone is no reason for resorting to so powerful a 
measure as blood-letting, in a disease which will pass through 
its stages under all circumstances, for there is no evidence that 
blood-letting ever lessens the number of pustules, or in any de- 
gree makes their inflammation less violent. For the manage- 
ment, therefore, of the simple precursory fever of small-pox, 
we must be content to adopt the highest antiphlogistic treat- 
ment, without a resort to blood-letting. The bowels should be 
freely opened, and the patient exposed to the action of cool air ; 
while cool, acidulated drinks ought to be freely given. 

The same objection will not exist as to bleeding, when symp- 
toms of local inflammation or congestion of important organs 
show themselves. Here we must at once resort to bleeding, to 
arrest the inflammation which we have seen often produces a 
rapid disorganization of structure. So, also, in the case of con- 
vulsions, which are very common in infants, no remedy is so 
immediately efficacious as bleeding, to the extent of eight or ten 
ounces, for children between the ages of six and twelve years. If, 
therefore, we find a child labouring much in respiration, and 
exhibiting the usual symptoms of a determination of blood to 
the pulmonary system, a very common occurrence in this 
disease, or by screaming and shunning the glare of light, with 
great heat in the head, and a highly flushed face, indicating a 
great determination of blood to the head, bleeding, either locally 
or generally, or both, must be our principal resource. It is, 
therefore, to the actual condition of the system, as well as to 
the prevailing type of the disease, that we must look to guide 
us in the use of blood-letting. There is in some individuals so 
complete a prostration of strength, even with the great heat of 



446 DISEASES OF CHILDREN. 

the surface, that bleeding would be extremely hazardous, al- 
though a local phlogosis actually exists. In such cases there 
is a great degree of languor, with nausea and vomiting. Here 
any bleeding would be attended with great danger. Under 
other circumstances, where there is clearly local disorder pre- 
vailing, the general condition of the system will not admit of 
any other depletion than the cautious abstraction of blood by 
leeches. 

Where there is great nausea, with a foul tongue, and no ten- 
derness of the epigastrium, there has probably been some de- 
gree of costiveness during the period of incubation, and the 
irritation of the accumulated contents of the stomach will need 
an emetic for their removal. Emetics are only admissible in 
the earliest period of the disease, when the sickness is produced 
by the action of the undigested food and viscid secretions. 
When it arises afterwards, and is attended with much pain, 
especially on pressure, an inflammation of the mucous coat 
exists, which demands the loss of a little blood ; after which 
fomentations may be applied to the epigastrium. 

These are the only circumstances which will warrant the use 
of any powerful measures in the treatment of the febrile stage 
of small-pox ; but as was before remarked, in the ordinary fever 
of this disease, a cooling regimen, and a hard mattress and light 
bed-clothes, with the occasional use of mild aperients, are de- 
cidedly the safest measures. As a refrigerant, the nitrate of po- 
tass may be used, as it diminishes the strength of the pulse, 
and increases the secretion of urine. It is much more useful 
in older children than in infants, from its too powerful action in 
weakening the vascular action. It has been objected to by 
Berends in acute exanthemata, from a supposition that its seda- 
tive effects on the superficial capillaries, prevent the develope- 
ment of the disease. Henke, however, approves of its use in 
those cases in which it may be employed in adults ; and it has 
Jbeen recommended by other practitioners, to alleviate the vio- 
lent excitement which precedes the eruption of small-pox. It 
may be given to children of from one to three years old in the 
dose of two or three grains, and five or six grains to those from 
eight to twelve. As adjuncts, the super-tartrate of potash, or 
the solution of acetate of ammonia may be given, to accomplish 
the object we have in view. Acids should seldom if ever be 
given to young infants. Cold water is the best refrigerant that 
can be used for them, and it may be given frequently with per- 
fect safety to all children. The body may at the same time be 
sponged with cold water, which will greatly lessen the febrile 
lieat, and it is said will also diminish the number of pustules. 






EXCERNENT SYSTEM. 447 

While the refrigerant plan is pursued, care must be taken 
not to produce a feeling of chilliness, which will greatly depress 
the vital powers. This is of more importance as the stage of 
maturation approaches. At this period there is no abatement 
of the high excitement, and a perseverance in the cold system 
to an undue extent may be productive of great debility. There 
ought also to be caution used in the application of cold to the 
surface, when there is much inflammation of the bronchial or 
of any part of the pulmonary system. With this course there 
will be every prospect of greatly lessening the danger in the 
subsequent stages of the disease. The opposite course, although 
not carried to the extent formerly practised, will but make the 
stage of inflammation and suppuration much more severe and 
dangerous, and will change the character of the eruption from 
the simple to the confluent. 

During the stage of maturation the same general plan of treat- 
ment should be pursued, modified according to the circumstances 
of the case, unless the symptoms should indicate great prostra- 
tion, or nervous irritation. It has been the custom to resort at 
once to tonics and stimulants in this stage. Some mild stimu- 
lant may at times be necessary, such as wine whey, where 
there is great depression of the strength during the suppuration 
of the pustules, and in cases of great malignity, accompanied 
with petechias and hemorrhage. Small doses of camphor may 
also be needed under similar circumstances. But the cause of 
this state is often found in the great state of irritation which the 
body suffers from the extensive mass of disease. Anodynes,, 
carefully administered, so as to procure sleep when there is 
much nervous commotion, will often relieve the state of pros- 
tration which the patient suffers. 

The great relief which children obtain from a copious diar- 
rhoea, in this stage of the disease, naturally suggests the use of 
aperient medicine, where the bowels are not thus naturally 
affected. These are especially needed where recourse has been 
had to anodynes to procure sleep, and to allay the excessive 
derangement of the nervous system ; a course more necessary 
in children than in adults, from the great and rapid exhaustion 
of nervous power. 

At this period of the disease a severe inflammation is liable 
to occur about the throat, at times completely preventing 
deglutition. Inflammation also invades the larynx, trachea, 
and bronchiae, accompanied with the usual symptoms of short 
and laborious breathing, and an appearance of threatening 
suffocation. Local bleeding is the remedy which promises the 
quickest relief under these circumstances, from the front part 
of the neck, over the larynx. If much excitement continue, 



448 DISEASES OP CHILDREN. 

antimony, or calomel and ipecacuanha* may be given every 
two hours, until the breathing is relieved. This local affection 
requires a prompt application of remedial measures on its first 
appearance, to prevent the serious ulceration and disorganiza- 
tion of the part, which we have seen so frequently attend this 
disease. 

The tumefaction of the face is often a painful and distressing 
affection. The ulceration and closure also of the eyelids may 
lead to serious consequences. They may be anointed with 
any soft, simple ointment, or cold cream ; and if the eyes are 
much inflamed, the subjoined wash may be used.f The punc- 
ture of the large pustules and blistered surfaces will afford 
great relief, similar to that obtained by the opening of an 
ordinary abscess, or the evacuation of the serum from beneath 
the distended cuticle of an artificial blister. Where the pus- 
tules discharge from beneath the scabs a thin, sanious fluid, it 
may be absorbed by means of finely powdered starch, or flesh 
powder. The hair should be closely cut ; otherwise, in severe 
confluent cases, it may become a source of great irritation, 
from becoming matted with the discharge from the suppurated 
pustules. 

It is towards the close of the suppurating period that the 
greatest debility is apt to arise, with cold extremities, petechia?, 
and other unfavourable symptoms. In such cases mild tonics 
may be needed, with diet of a more stimulating and nutritious 
character than that which is appropriate through other stages 
of the disease. 

There is, especially in children, when affected with inflam- 
mation about the fauces and larynx, often a great accumula- 
tion of viscid mucus and saliva. This may be removed by 
syringing the fauces with vinegar and water, or diluted oxymel, 
or solutions of borax and honey diluted. When the fauces 
become ulcerated and offensive, diluted tincture of myrrh, or 
a weak solution of the chloride of soda, will be necessary to 
relieve this unpleasant symptom. Mild emetics may also be 
required at this period/ of the disease, to remove the morbid 
secretions from the throat and bronchise. 

The stage of desiccation, or convalescence, needs a mild tonic 
course, which will be gradually resorted to on the subsidence 
of the inflammatory symptoms in the third stage. The feeble- 
ness and wasting of the body, and the necessity of a restoration 

* fy Pulv. Ipecac, t Ifc Plurabi Acetat., gr. v. 

Hydr. Subm., aa. gr. xv. Aqua?, §iv. M. 

Sacchar. Alb., 3ij. M. 
Divid. in pulv. No. xii. 
One every two hours. 



EXCERNENT SYSTEM* 449 

to the usual course of living, are the indications of the proper 
course to be pursued. 

The prophylactic treatment consists either in inoculating 
from a variolous patient, or by the process of vaccine inocula- 
tion. The former, however, is entirely superseded by vacci- 
nation, which, while it affords an equal chance for escape, also 
presents the additional advantage of entirely exterminating 
small-pox ; the increase and spread of which, variolous inocu- 
lation assists. The subject will be resumed when speaking of 
vaccinia. 

VARIOLOID. 

Differences in the appearance and structure of small-pox 
eruption have long since been noticed ; some having a crystal- 
line or lymphatic appearance, others being hardened or corneous, 
ichorous or emphysematous in their nature. According to 
these various appearances they have received the names of 
lymphatic-pox, horn-pox, serous-pox, etc. In such, also, as have 
at the commencement the true characters of the inflamed eleva- 
tion of small-pox, an imperfect formation of pus takes place, 
the suppurative process stops, and the pustule shrinks. 

These differences have been observed to occur in epidemics, 
the developement being modified by the action of the cause of 
the disease ; various grades and forms being occasionally thus 
produced. 

But the most common cause of the difference in the eruption 
of small-pox, is the influence the constitution of the individual 
has upon it ; for every variety which has been noticed will 
occur during the prevalence of the disease in the same place. 
Some will escape altogether; no susceptibility existing from 
hereditary or individual peculiarities. Others, when passing 
through the disease, exhibit the ordinary symptoms, variously 
modified from the same cause. The previous ill health of the 
patient will control in some degree the character of the eruption; 
and in some unknown states of the system the progress of the 
eruption is checked. 

The usual source of partial immunity is the previous attack 
of the disease, or the prophylactic measures adopted, whereby 
the patient has been subjected to the influence of the same, or 
of a kindred affection. It has been long known that persons 
who have had the small-pox, either naturally or artificially 
produced, were sometimes attacked with the disease a second 
time, and occasionally in a very severe form. It has also been 
remarked, that the secondary disease rarely exhibited the 
strongly marked characters of the first, and presented likewise 
the characters of the spurious form. Whenever small-pox 

57 



450 DISEASES OF CHILDREN. 

attacks a second time, it usually exhibits the appearances of 
the crystalline variety. 

At the time when vaccination was introduced, little attention 
was bestowed on the fact, that small-pox would affect a person 
a second time ; and it appears to have been overlooked, or, at 
least, regarded as a circumstance of exceedingly rare occur- 
rence. But the numerous examples of varioloid eruptions 
occurring after vaccination, which process had afforded so 
many proofs of the protecting power of the disease thus com- 
municated, led to a more close and critical examination of the 
nature and character of these eruptions. The result of these 
investigations is, that a modified disease will occur at times, 
both alter small-pox naturally taken or artificially induced, and 
also subsequently to the process of vaccination. Vaccination 
is not a perfect security from an attack of small-pox ; but in- 
stances occur where, on an exposure to variolous contagion, a 
disease having a close resemblance to variola, but generally 
void of danger, will sometimes attack the vaccinated individual. 
This varioloid disease occurs more frequently where the 
genuine variola is most severe and fatal ; showing that the 
augmented malignancy of the variolous contagion is, in general, 
the cause of the defective protecting power of vaccination, 
and producing in some a modified small-pox, but with symp- 
toms sufficiently approximating to that disease, to render them 
identical. 

Although a previous attack of small-pox, either natural or 
inoculated, produces some modification in the second, yet there 
is no agent so powerful in modifying small-pox as vaccination ; 
for the characters of the disease are much more changed in such 
as have undergone this process, than in those who have passed 
through the former. This modified disease, or varioloid, is that 
which I shall now consider. The causes of these modifica- 
tions, if they have their origin in any thing that affects the 
proper developement of vaccine, will more properly be the 
subject for consideration under the head of vaccination. The 
different conditions of susceptibility to small-pox, and the 
effects of severe variolous contagion, have already been alluded 
to. The influence of this agent in producing varioloid after 
vaccination, is of much more frequent occurrence than a second 
attack of small-pox. This subject will also be referred to in an- 
other place. 

The identity of the small-pox with the modified disease 
occurring after vaccination, has been questioned by some, but 
no doubt, I think, can exist that the disease is the same, having 
undergone an alteration, from the partial immunity secured by 
the individual by the influence of vaccination. During the 



EXCERNENT SYSTEM. 451 

prevalence of small-pox, the appearance of the varioloid erup- 
tion, it is observed, will occur in many vaccinated individuals, 
evidently proving it to depend on the variolous epidemic. The 
contagion, also, in a family where there are some who have 
been protected by vaccination, and others who have not been 
thus protected, has been traced from one to the other, either 
appearing as the variolous or varioloid disease, depending on 
the condition of the patient, and communicating either one or 
the other, according to the protected or unprotected state of 
the individual first attacked.* The facts connected with the 
appearance of varioloid in the United States, correspond re- 
markably with those which existed in London forty years since. 
Varioloid has also been produced by inoculating those who 
had been previously vaccinated with the matter of variola. 
Numerous evidences of the variolous origin of the disease, 
known by the name of modified small-pox, are found in the 
elaborate work of Dr. Thompson, of Edinburgh.f 

Varioloid is characterized by the comparative mildness, and 
generally by the short duration of the precursory fever, and 
the occurrence of a perfect suppuration in the eruption. 

The fever is often so mild as to attract but little attention. 
In a few instances, however, it is severe, but not of long dura- 
tion ; and like the milder form of variola, it disappears on the 
commencement of the eruptive stage. The febrile stage is also 
irregular as to its period, varying from two to five days ; at the 
end of which time a slight redness, of an erythematic character, 
shows itself, particularly on the face. The minute spots of 
varioloid then appear, gradually assuming the form of small 
papular eruption. In general these dry away in the course of 
five or six days, leaving an indurated spot ; a few, however, 
having a pustular, and others a vesicular appearance. The 
eruption is various as regards the number ; in some instances 
there are but a few scattered in different parts of the body, and 
in others they cover closely the face, trunk and limbs. 

The common or indurated spots are quickly dried up; those 
which suppurate become umbilicated ; a dry scab forms on the 
fourth day, and usually falls off about the eighth. The vesicles 
bear some resemblance to the vaccine inoculated pock; and from 
their rapid progress, and crystalline or watery appearance, have 
been regarded as identical with varicella. 

There is rarely if ever any fever during the eruptive stage, 
and the desiccation generally commences on the fifth or sixth 



* V. History of the Natural and Modified Small-Pox, etc., by John K. Mitchell, 
M. D., and John Bell, M. D % , N. A. Med. and Surg. Journ., vol. ii. p. 244. 
t On the Varioloid Epidemic ; Edinburgh, 1820. 



452 DISEASES OF CHILDREN. 

day. On the separation of the scabs, discoloured spots, or slight 
elevations, are left, having the appearance of warts ; rarely are 
there any pits formed by the pustules of varioloid. 

It is difficult, when the disease is severe, to distinguish it from 
small-pox, the fever being equally violent, and the eruption as 
abundant. It may, however, be distinguished by the small size 
and papular or tuberculated character of the pustules, the lighter 
colour of their contents, the irregularity with which they ap- 
pear, coming more in successive clusters than simultaneously, as 
is the case in genuine variola. Many observers have remarked 
an areola around the varioloid pustule, resembling that which 
surrounds the vaccine vesicle, giving it an appearance of both 
diseases. This has also been noticed when an individual has 
passed through both affections at the same time. The desicca- 
tion also takes place at a much earlier period than in variola, 
and the scabs separate about the eighth or ninth day. 

As regards the treatment of this affection, it differs in no re- 
spect from that of variola, and in most instances scarcely re- 
quires any treatment. Where the febrile action is high, a little 
blood may be drawn and a purgative administered. Diaphore- 
tics, also, are useful during the existence of fever. 

VARICELLA.— CHICKEN-POX. 

Another form of modified small-pox is an eruptive affection, 
the characters of which are well indicated by its name, varicel- 
la, given to it by Reverius, who wrote on this subject about 
the middle of the seventeenth century. The terms crystal- 
line, lymphatic, spurious small-pox, also point out its nature 
with considerable accuracy. Long before this period, descrip- 
tions were given of spurious eruptions, having something of the 
appearance of variola, but which imparted no protecting influ- 
ence against a second attack of that disease. Sydenham has 
also given an account of an imperfect form of small-pox, which 
gives no security against the variolous contagion. Morton also 
described the same disease, but adopted the popular name of 
chicken-pox ; and all writers speak of the occurrence of a spu- 
rious small-pox, corresponding with the accounts of these 
authors. 

Etiology. — There have been differences of opinion with re- 
gard to the origin of this disease, but all unite in the fact of the 
occurrence of imperfect, or spurious*cases, destitute of the pro- 
tecting property either of variola or vaccinia. Those who 
have contended for the distinct origin of varicella, have not sa- 
tisfactorily established the fact of its being independent of va- 
riola, and differ from each other in relation to their pathological 
inferences. 



EXCERNENT SYSTEM. 453 

Dr. Heberden was the first who attempted to establish dis- 
tinctly the fact of the difference between small-pox and chicken- 
pox, referring it to the action of a distinct contagious principle. 
His paper was published in the year 1767.* Cullen, also, 
adopted similar views.f Others, on the continent of Europe,. 
Sauvages and Burserius, regard it as a modification or variety 
of small-pox. Subsequent investigations have satisfactorily de- 
monstrated that it owes its origin to the influence of variolous 
contagion, equally with the various appearances of small-pox, 
described by the older writers. This opinion is adopted by 
Dr. Thompson, after a very laborious and close investigation 
into the causes and nature of variolous diseases, as they occur- 
red in Scotland. The same views are held by others. 

Wherever the small-pox has prevailed, there has been, as 
before remarked, a variety in its appearance in different sub- 
jects. In some there is a light and crystalline eruption, that is 
so modified, either by the temporary condition of the individual, 
or by some mildness in the variolous contagion, by which an 
epidemic will be at times characterized, that it passes but im- 
perfectly through its course, never passing beyond the vesicu- 
lar condition which marks the first minute appearance of the 
pustule in small-pox, while the other concomitant symptoms 
exhibit a similar mildness and imperfection in their develope- 
ment. These are essentially different from another appearance 
which small-pox assumes, when modified by vaccinia ; in this 
spurious disease, the pustule assumes the marks which charac- 
terize both diseases, but is essentially pustular in its nature, 
with the central depression which marks small-pox. From 
this circumstance, it has received the names of varioloid and 
pustular varicella, while the still more imperfect, or crystalline 
variety, has been called vesicular varicella. 

The fact has been questioned of the variolous origin of the 
chicken-pox ; but, after the abundant proof furnished by Dr. 
Thompson and others, of its connection with variola, there can 
scarcely exist a doubt on the subject. A condensed summary 
of the objection, and the arguments in favour of this opinion, 
may be found in Eberle's Treatise on Children.t 

Whatever views may be adopted, it is of little practical im- 
portance whether the disease originates from specific contagion, 
or in common with variola, compared with its proper descrip- 
tion and diagnosis, as it affords no protection against a second 
attack of small-pox. It is therefore <of some importance to be 



* Transact, of the Royal Col. of Physicians; Lond. vol. i. p. 427. 
t Synop., vol. ii. p. 134. 
t Page 419. 



454 DISEASES OF CHILDREN. 

able accurately to distinguish chicken-pox from its kindred 
affections. 

Like other forms of varioloid affections, chicken-pox is pre- 
ceded by febrile symptoms, of a slight character, and often on 
this account unnoticed. Its continuance is from twelve to 
forty-eight hours ; rarely longer than this. The child is a little 
languid, and complains of a slight head-ache : seldom, however, 
are the symptoms sufficient to interfere with the usual occupa- 
tions of the child. Although this is the type of the precursory 
fever, it is not thus uniformly mild ; but symptoms similar to 
those preceding small-pox have at times been noticed. 

The eruption on the first day of its appearance is marked 
by small red spots, superficial, sometimes of an oblong, and at 
other times of a circular form. In other instances, as these run 
into each other, their margins become irregular, when they 
have no definite shape. On the second day of the eruption, a 
vesicle is formed, containing a transparent, light straw-coloured 
fluid ; it is broad at its base, and becomes accuminated at the 
top. Other spots and vesicles sometimes arise, the bases of 
the vesicles being usually much inflamed. On the following 
day the contents of the eruption becomes of a deeper yellow. 
On the fifth day a minute scab is formed in the centre of the 
vesicle, giving it something of the depressed appearance of a 
small- pox pustule. This form does not occur in all ; some 
are thus umbilicated, others are conoidal, and some globose; 
the latter has also received the name of swine-pox. On the 
sixth day a small scab occupies the place of the vesicle, which 
falls off on the seventh or eighth day. 

It is attended with severe itching, especially in children, and 
the eruption being thus often broken, the characters are very 
soon effaced. 

The disease is occasionally confluent ; the general symptoms 
are then much more severe. 

The diagnosis of the disease may be made by attending to 
the following pathognomonic symptoms. 

Varicella has a peculiar odour, decidedly different from the 
marked fetor of variola. The eruption of chicken-pox, unlike 
that of small-pox, appears over every part of the body, com- 
mencing on the trunk. It is well known that in the last men- 
tioned disease the eruption commences on the head and neck. 
In chicken-pox the eruption is usually completed in twenty-four 
hours, some vesicles appearing irregularly afterwards. The 
small-pox, however, does not show itself until the third or fourth 
day, and proceeds regularly on its course. The vesicles of 
chicken-pox are filled with a whitish lymph, and never with 
thick, purulent matter; they become shrivelled on the fifth 






EXCERNENT SYSTEM. 455 

or sixth day, but do not exhibit the incrustation of small- 
pox. In some instances they have the appearance of the de- 
pression observed on the pustules of small-pox, but close exami- 
nation will detect the difference. The whole aspect of the 
varicellous eruption is much more pointed than in the other 
disease. 

It is so mild a disease as scarcely ever to require any treat- 
ment. If, however, it should become severe, the same princi- 
ples which are adopted in small-pox are applicable to chicken- 
pox. 

VACCINIA..— COW-POX. 

The disease now to be considered has become one of the 
most important which has at any time occupied the attention of 
the physician. As a prophylactic remedy for another affection 
of a very fatal character, it has been regarded as the greatest 
boon to mankind in the healing art — the only means left for the 
effectual prevention of that loathsome scourge, which seemed 
almost to threaten with extermination the entire population^ 
wherever it commenced its fatal ravages ; and which, on our own 
continent, in those remote parts where science has not inter- 
posed her protecting hand, has in truth swept whole tribes of 
the human race from the earth. The benefits, however, which 
at first were thought to be complete, and the protection uni- 
versal, have, in some instances, been found to be partial ; and 
doubt and distrust have been allowed, in the minds of a few, 
to take the place of the unlimited confidence hitherto so fully 
bestowed on the powers of the vaccine disease. Its impor- 
tance, therefore, increases with the number of failures, either 
partial or complete, in its protecting power, and with the ne- 
cessity which now exists for a close and impartial investigation 
into the causes which have thus produced uncertainty in the 
results. 

Before considering the artificial introduction of the disease 
into the system for protection against the contagion of variola, 
it will be proper to take a brief view of the disease, and the 
characters it exhibits in its natural state. 

As the name imports, it is a disease affecting the cow ; and it 
has been supposed that this vesicular disease has been long 
known as peculiar to that animal, and has been transmitted to 
man. Pliny mentions in several places a papular disease by 
the name of Boa, which M. Phela, physician to the Pope, in a 
work published at Milan, in 1825, considers as a name designa- 
ting its origin from the cow. Having never seen his work, nor 
any other notice than one containing the simple statement above 
mentioned, I am unable to present any of his views in relation 



456 DISEASES OF CHILDREN. 

to the fact, or of his hypothesis founded on it, of the identity of 
the two diseases, and that small-pox is originally derived from 
the cow, and becomes altered by the influence of the human 
constitution.* 

The identity, however, of these two diseases, modified by 
constitutional peculiarities, has been more recently proved by 
well conducted experiments, in transferring variolous matter to 
the cow, and thus causing the vaccine infection. It was 
Jenner's opinion that the two affections were one and the same ; 
he therefore gave the name of variolas vaccinae to the vaccine 
disease, which he regarded as only changed by passing through 
the system of the cow. It is certain that an epozootic disease, 
having the characteristics of small-pox, has often prevailed in 
various districts of country, and at the time Jenner announced 
his discovery, had previously existed ; the disease, as noticed 
by Jenner, being but the remains of this epozootic malady. 

Dr. Sonderland, of Bremen, was the first who performed the 
experiment of infecting the cow from variola. His account 
was published in the German periodicals, in 1831. He took 
the woollen bed-clothes, which had been on the bed of a small- 
pox patient, who had died with the disease in its most aggra- 
vated form, and fastened them to the backs of cows. They be- 
came in a few days sick and hot, while a pustular eruption 
appeared on the skin, especially on the udders, having all the 
appearance of vaccina, and capable of producing the ordinary 
vaccine vesicle. Several attempts have been made to repeat 
these experiments, but they have in every instance been unsuc- 
cessful in producing a perfect disease. In some instances an 
eruption of a pustular character showed itself in the parts 
immediately in contact with the infected clothes. No proper 
vaccine vesicle, however, resulted from the use of lymph taken 
from these pustules, with which several children were ino- 
culated. 

The failures probably arose from some atmospheric or other 
peculiarity, for it is not under every circumstance that the 
cows are susceptible of the disease. The soil, and some 
other unknown influence of the situation in which they are 
kept, have been supposed to exercise a control on the develope- 
ment of the disease in them. Cows that are kept closely pent 
up are much more liable to the disease than others. Change 
of food, season of the year, and the age of the animals, also, 

* The following passages are found in Pliny : Boa appellator morbus papulo- 
rum cum rubentes corpora * * * Lib. xxiii, Cap. viii. * * * boam sanant, 
id est rubentes papulas. Lib. xxvi, Cap. xi. If the name of the disease be 
derived from Bc«<r, a cow or an ox, there may be some foundation for the fact 
above stated. 



EXCERNENT SYSTEM. 457 

have been found to exert a material effect on the appearance 
of the disease among them. The difficulty, therefore, of con- 
ducting a set of well-arranged experiments, from which similar 
results are to be obtained, is obvious ; and even in the more 
direct communication of the variolous infection to the cow by- 
inoculation, numerous failures may reasonably be anticipated, 
but can have no weight as evidence, when well authenticated 
instances of an opposite nature exist, even though small in 
number. 

The British and Foreign Medical Review* contains a very 
able digest of the amount of information existing on the iden- 
tity of the small-pox and cow-pox, in which the reviewer has 
summed up the experiments that have been made to prove 
this identity. Experiments have been instituted in different 
countries : in Russia and Great Britain with a similar result. 
Dr. Basil Thiele, of Kasan, in South Russia, and Mr. Ceely, of 
Aylesbury, in England, both had recourse to the inoculation of 
cows with variolous matter taken from the human subject, to 
test this question. 

Dr. Thiele at first tried without success the method of Dr. 
Sonderland. He then, in 1836, inoculated a cow with vario- 
lous matter, and from the disease thus produced, succeeded in 
giving the vaccine disease to several children, the vesicle having 
all the characters of the genuine vaccinia, but attended with 
more severe constitutional symptoms than is usual. During 
the period of two years following, upwards of three thousand 
persons were vaccinated with the virus that had originally come 
from the animals inoculated by him. Great care was taken 
in selecting cows with fresh milk, and between the ages of 
four and six years. He carefully kept them in a temperature 
of 66° Fahrenheit, and had them regularly fed and milked. 
With these precautions, and the insertion of the virus in the 
posterior part of the udder, where the cow could not lick it, he 
succeeded in producing the genuine vaccine disease. 

The other set of experiments, equally satisfactory, were made 
by Mr. Ceely, in Aylesbury, in England, and are detailed in 
the Report of the Seventh Anniversary Meeting of the Pro- 
vincial Medical Association, held at Liverpool, in July, 1839, 
on the present state of vaccination. 

Mr. Ceely, after a number of unsuccessful attempts to affect 
cows with variolous matter, applied in the manner previously 
done by Dr. Sonderland, by investing them with the blankets 
from the bed of a small- pox patient, and also by the insertion 
the virus, succeeded finally in inoculating, with variolous matter, 

* No. xvii., for January, 1840. 
58 



458 DISEASES OF CHILDREN. 

three young heifers, by means of punctures made in the labia 
pudendi. Another animal was vaccinated in the same manner. 
One of these cases affords a sufficient illustration of the pro- 
cess he pursued to determine the question. Variolous matter 
of the seventh or eighth day was inserted into the left labium 
pudendi, by means of seven punctures. Nine days after, the 
same animal was vaccinated on the right labium pudendi, with 
lymph taken from a child, with the same number of punctures ; 
and below the same labium with four punctures. On the tenth 
day after the insertion of the variolous matter, one of the punc- 
tures on the left labium pudendi had assumed the form of the 
vaccine vesicle. From this vesicle he charged several points 
with lymph ; and on the fifth day of the insertion of the vaccine 
virus the eleven punctures had become perfect vesicles ; he 
charged a number of points with clear lymph, and used it on 
adults and children. The vesicles on the two labia were the 
same ; and on the twenty-sixth day of the variolous, and the 
seventeenth day of the vaccine inoculation, the appearance of 
the scars were similar. The experiments were afterwards varied, 
and the animal subsequently inoculated both with variolous 
and vaccine matter, without any result following. The vesicles 
corresponded in every respect with those delineated by Jenner. 
No doubt can now exist of the identity of the two diseases, but 
varying under the circumstances arising from the peculiarities 
in the constitution of the animal. 

As to the origin of the disease, much greater difficulties 
exist than in proving its identity. By some it is believed to 
be the variolous disease modified by passing through the cow. 
Others have thought, as was remarked above, that the original 
disease existed in the cow, from the name by which a similar 
disease, supposed to be the small-pox, was designated in 
former times, and that it became modified into the variolous 
disease by the influence of the human constitution. Expe- 
rience, however, appears to prove the reverse of this, and the 
name gives no further proof of its true origin than vaccinia 
does at the present day. Others ascribe the formation of the 
vaccine vesicle to the matter from the heels of the horse, affect- 
ed with a disease, and supposed to be the same as is known as 
the grease, javart or eaux aux jambes, of the French. 

This affection, it would appear, exists, variously modified, in 
several animals ; for numerous facts go to prove that, according 
to the laws of immunity observed in the variolous disease, no 
second attack is likely to occur when either men or quadrupeds 
have passed through a disease bearing the general marks of 
variola, from what source soever it may be derived. Thus, 
the same exemption exists among those who attend flocks of 



EXCERNENT SYSTEM. 459 

sheep, and have taken from them a mild, eruptive disease, ac- 
cording to the information obtained from the native tribes in 
India, by Mr. Bruce, Consul at Bushire ;* as is found to be the 
case with those who have had the matter of the grease, or the 
contents of a vaccine vesicle from the cow, casually transferred 
to them. It has also been asserted that sheep will be protect- 
ed from this eruption by inoculation with variolous matter, f 
These facts show that these epidemic and epizootic diseases 
are derived from one source. 

It is certainly very difficult to trace to its origin a disease 
which assumes such difference in its appearance, and which is 
equally communicable from one animal to another. Cows, 
sheep and horses, all have a d isease, which, although at times appa- 
rently occurring without being traceable to any distinct source, 
yet may also be transmitted from any one, but presenting 
shades of difference, by which each can be distinguished from 
the other ; while in man a similar one arises, marked, as its 
distinctive characters, by its violence, loathsomeness, and ex- 
treme fatality. The latter disease, as has been seen by actual 
experiments, will develope the former ; but the epizootic ma- 
lady will only produce its like in the human system. Does not 
this fact appear to sustain the idea, that the vaccine disease, 
and its kindred affections, are offsets and modifications of the 
variolous disease — a sort of abortion or imperfect develope- 
ment of the most violent form which it uniformly assumes in 
man ? Such changes appear to be the course generally ob- 
served throughout the other departments of nature, and dis- 
eases exist in their most perfect form of virulence in man. 
When occurring in quadrupeds, they appear as much milder 
affections, and are rarely, if ever, fatal ; as is seen during pes- 
tilences, affecting both man and beast. If, therefore, its origin 
is to be sought by tracing its communication, it seems more 
natural to refer it to the disease as it affects man, where it is 
uniformly more severe and fatal, and in whom it consequently 
must be regarded as most perfect in its developement. 

In the cow, vaccinia appears as an inflammatory disease of 
the udder, which is communicable by contact ; for it has been 
observed to spread throughout a herd very soon after one cow 
is affected. It shows itself, at first, in the form of small, red 
elevated points beneath the skin; these afterwards become of 
a bluish white, and contain a fluid, at first thin, limpid and white. 
Some exhibit a pearl colour, or a whitish yellow ; afterwards, 
opaque and purulent. These eruptions appear both on the teats 

* Mediz. Chirur. ; Zeit., 1809. 

t Extract of a Letter to W. Erskine, Esq., Trans, of the Soc. of Bombay. 



460 DISEASES OF CHILDREN. 

and udders ; but Jenner considers the teats as the only part 
where the genuine disease is seated. He also regards the dis- 
ease which occurs on the udders, having a resemblance to cow- 
pox, as not the genuine affection, it being often induced by the 
practice of the dealers, when, bringing their cows for sale, ab- 
staining from milking them, that an undue distention may take 
place. 

The vesicles differ in number, but they have sometimes 
amounted to twenty or thirty, about the size of a pea ; in other 
instances they are as large as a hazelnut. They are usually 
circular, with a central depression ; the latter, however, is not 
uniformly well marked, and is at times entirely absent. The 
structure of a true vaccine vesicle is cellular, and has been com- 
pared to the pulp of a lemon ; on this account it does not rea- 
dily discharge its contents on being opened or ruptured. The 
spurious pock, on the contrary, is easily lacerated, and the 
whole fluid contents flow out at once. The colour, also, is 
some indication of the genuineness and purity of the lymph. 
The bluish, pearly, yellowish, or purulent pock, is not to be 
depended on for producing the proper protecting vesicle. An 
areola, distinct and circumscribed, of an erythematic inflam- 
mation, surrounds the pock, and is another evidence of its genu- 
ineness. Such as are destitute of this, or where it is remarkably 
pale, or where, in its place, there is a hardened state of the sur- 
rounding parts, with deep seated inflammation of the cellular 
tissue, but little reliance, according to the experience of Jenner 
and others, ought to be placed on it, for yielding the proper 
lymph. 

Where cows have been vaccinated, the first appearance of the 
disease is on the sixth day ; when taken accidentally, it is said 
to be on the third or fourth day, and the vesicles attain their 
maturity on the eighth, ninth or tenth day, when a scab com- 
mences in the centre of the pock. 

The constitutional symptoms are sometimes severe, and at 
other times entirely absent. It has been attempted, from the 
existence or absence of loss of appetite, fever, secretion of milk, 
etc., to make a diagnosis between the genuine and spurious dis- 
ease ; but these constitutional derangements have been found 
to exist in the genuine and spurious diseases, and cannot be re- 
garded as of any account. Jenner, Dr. Herring and others, do 
not consider constitutional disturbance as essential to the exist- 
ence of genuine cow-pox. 

This affection is sometimes contracted casually by those en- 
gaged in milking, when it affects principally the ends of the 
fingers. This is usually a much more severe disease than that 
artificially induced, from the great number of vesicles pro- 
duced, and the fever, rigors, and swelling of the axillary glands. 






EXCERNENT SYSTEM. 461 



VACCINATION. 

The protecting powers of the vaccine disease appear to 
have been perfectly well known to the nomadic tribes in Hin- 
dostan and the Chinese, according to the statement of Mr. 
Bruce* and the researches of M. Moreau de Jones. f But 
this fact does not in the least detract from the admirable dis- 
covery of Jenner, in 1796, J who, in Berkley, near Gloucester, 
where the disease was found to prevail extensively among the 
cows, first conceived the idea of applying it for the prevention 
of small-pox, from having observed that the dairy maids, and 
such as had contracted the disease accidentally from the cow, 
were thereby protected from the infection of small-pox. 

After having, in the month of May, vaccinated a boy from 
the ulceration on the hand of a dairy maid, he tested the patient, 
by variolous matter taken from the pustule two months after- 
wards. The experiment was again repeated, but without any 
sensible effect on the constitution. During the period of two 
years several similar experiments were tried with the like result, 
when his discovery was publicly made known. 

In the year 1799 the discovery was announced in the United 
States in the Medical Repository, published in the city of New- 
York ; and in July, of the following year, was first successfully 
practised by Dr. Benjamin Waterhouse, Professor of Medicine 
in the University at Cambridge, Mass., on four of his own 
children. 

The proper age for vaccinating a child is from the second to 
the fourth month, the period when the body is sufficiently 
developed to receive and mature the disease, and before the 
irritation of the system from teething has occurred. Children 
have been vaccinated before the period above mentioned, even 
within the week ; but the sanguineous congestion of the skin, and 
the great tendency to inflammation from this cause, on the 
slightest irritation, may be productive of an erysipelatous affec- 
tion, or excite a chronic inflammation, which are often very 
tedious and unmanageable when once formed. After the 
second month the vaccine disease appears to proceed with 
more uniform regularity, and is attended with less febrile irri- 
tation than at an earlier period. Should the small-pox prevail, 
we should not wait however, but it may, under such circum- 
stances, be performed within the month. The season of the 
year is also of some importance to the success of vaccination. 



* Epist. Cit. 

t Archiv. Gen. de Med. ,t. xiii. 

t Enquiry into the Causes and Effecls of Variolar Vaccinas j London, 1798, 



462 DISEASES OP CHILDREN. 

The heat of summer is unfavourable to the proper performance 
of this operation, and it more often fails during this season than 
any other ; the free secretions from the skin removing the 
virus when inserted. The tendency, also, to inflammatory 
eruptions in hot weather, renders the operation liable to excite 
the skin to inflammation. Extreme cold, also, acts unfavourably 
on the proper success and full developement of the vaccine 
vesicle. It ought, therefore, to be performed, if possible, in mild 
weather. The spring, and commencement of summer and 
autumn, are the best seasons for vaccinating. 

The proper virus is that which is taken on the eighth day of 
the disease, before the areola has showed itself. It sometimes 
happens that the incubation is protracted, and the vesicle is not 
so much advanced on that day as is necessary to obtain virus 
which will secure the formation of a proper vaccine vesicle ; 
this often happens without the disease being affected. The 
taking of the matter may, under these circumstances, be de- 
layed until the vesicle is filled. 

It is sometimes deemed advisable to preserve the vaccine 
virus in a dried state. The usual method of doing this is to re- 
ceive it on the convex surface of the extremity of a piece of 
quill, or on the small ivory teeth of a comb, when it is to be pre- 
served but a short time. The part to be charged with the virus 
should be slightly roughened by scraping it ; a greater quantity 
will in this way be made to adhere. It may also be preserved 
by receiving it on the surface of a square piece of flat glass ; 
another piece, of the same size and shape, is then applied to the 
surface containing the virus ; and both secured by coating the 
edges with wax, and wrapping them in dark coloured paper, to 
exclude both air and light. Dr. Jenner's plan was to receive 
it in a cup-like cavity, formed on the surface of a perfectly 
smooth plate of crystal or glass ; over this was applied another 
smooth piece with an even surface, by which means the virus 
is preserved fluid, the edges being closely luted. 

Another method is by means of small, delicate tubes, drawn 
out in capillary points. These are charged by applying the 
smallest extremely horizontally to the drop of lymph, which 
passes into the tube by capillary attraction. This is repeated 
until the tube is filled, when it is hermetically sealed by fusing 
it in the flame of a lamp. Tubes thus charged may be enclosed 
in the barrel of a quill, and the virus used even after the lapse 
of some years. 

Scabs may also be used, for the virus can in this way be pre- 
served for several months ; it ought to be taken from vesicles 
that have not been broken. A proper scab should be circular, 
of a mahogany colour, and hard in its texture. 



EXCERNENT SYSTEM. 463 

The following are the characteristics of good vaccine virus. 
It issues slowly from the vesicle, owing to the cellular structure, 
and assumes a spherical shape. It is adhesive, and imparts the 
sensation of syrup when taken between the fingers. It dries 
rapidly on whatever it is received, having the appearance of 
dried gum arabic. When covering the surrounding skin, espe- 
cially if the latter be red, it has a bright silvery lustre. It 
mixes with difficulty with blood ; and when a piece of quill is 
stained with it, on which there is accidentally a little blood from 
the puncture, it does not colour equally every part that has re- 
ceived the virus. 

When the scab is used it should be cut, and a small quantity 
scraped from the smooth surface; this ought to be mixed with 
cold water, and the paste thus formed may be used for vacci- 
nation. The virus of the scab may also be preserved by pul- 
verizing it. and forming it into a paste with water, which may 
be placed between two pieces of square glass and tightly se- 
cured ; to be moistened when it is to be used. 

The different methods that have been adopted for inserting 
the vaccine virus, are, by friction, vesication, puncture and 
scarification. 

The first mentioned process is now altogether abandoned, 
from its uncertainty and extreme pain ; it is performed by means 
of a piece of rag passed briskly over the surface, until the cuti- 
cle is excoriated. A small blister has also been much in use ; 
but the pain and soreness, and the length of time required, make 
this method also objectionable. 

When the method by puncture is adopted, it is best performed 
by a sharp lancet introduced beneath the cuticle, so as to ele- 
vate a considerable portion. Under this the recent virus may 
be introduced from the blade of the lancet, or that which has 
been preserved on a sharp point of a piece of a quill may be 
applied, by introducing it, and keeping it for some time in its 
place, by pressure with the thumb or finger. When it has been 
held a sufficient time to allow of the solution of the virus, it 
may be withdrawn while the pressure is still continued, that it 
may be completely wiped off. 

Another method, and that most commonly in use in the Uni- 
ted States, is by scarification. About half a dozen parallel 
scratches are made, about a line in length ; these are crossed 
by others, and when the blood has ceased to ooze from them, 
but before they become perfectly dry, the virus is applied by 
gently rubbing them with the lancet, or whatever else is charged, 
until it is wholly wiped off by the serum that moistens the 
scratches. It should then be permitted to dry on the part, and 
great care observed that it be not rubbed or washed during 



464 DISEASES OF CHILDREN. 

the period of incubation, which will interrupt the proper deve- 
lopement of the vesicle. Pieces of the barrel of a quill, used to 
vaccinate according to this method, are much broader than those 
used for insertion in a puncture, when they are sharpened at 
the point. 

The spot usually selected as being the most free from the 
danger of friction, is in the arm, near the insertion of the del- 
toid muscle. 

The number of punctures does not appear to be of as much 
importance to the full effect of the vaccine virus as has been 
thought by some, if we may judge from the extensive immunity 
from small-pox enjoyed in this country, where it is customary 
to have but one vaccine vesicle. The better, however, to en- 
sure the success of the virus, two or three points of insertion 
may be made. This method may also be resorted to, if it is 
intended to take virus from the child. In France, it is recom- 
mended by M. Husson to have three punctures made on each 
arm, and in some parts of Germany and Prussia, as many as 
twenty-four; but instances of severe inflammation and slough- 
ing have occurred where several punctures have been made. 

The first appearance of a successful vaccination shows itself 
about the commencement of the third day, in the form of a mi- 
nute spot of inflammation. On the fourth, it has the shape of a 
small conical tumor or pimple, which is attended with itching. 
On the fifth day it enlarges, and is surrounded with a narrow, 
bright red belt, while the pimple has assumed the appearance 
of a vesicle. A depression about this time appears in the cen- 
tre, of a fawn colour, which is much more strongly marked on 
the seventh day ; its margin is white, and distended with lymph. 
On the ninth day, the vesicle arrives at its perfect state, when 
it is fully distended, with the central depression in the form of a 
large brown scab. 

At this period the constitutional disturbance, which takes 
place to a greater or less degree, in most cases shows itself. 
This may appear simply in the form of a slight restlessness. At 
other times there are chilliness and fever, with tumefaction of 
the axillary glands. About the tenth day the rim containing 
the lymph loses its brilliancy, and becomes flatter, while the 
surrounding inflammation is much increased, and is attended 
with great swelling and hardness, and often with heat and pain. 
On the eleventh day the vesicle is more flattened, and its con- 
tents are more yellowish, while the central depression extends 
and becomes darker, or of a mahagony colour. From the 
twelfth to the fifteenth day the vesicle is quite flat, and the 
desiccation increases towards the circumference ; the inflam- 



EXCERNENT SYSTEM. 465 

matory circle at the same time diminishes, and becomes much 
paler. The scab loosens at the circumference, but remains 
attached at the centre, until the twenty-first to the twenty-fifth 
day, when it detaches itself and falls off. The scar remains 
for a time red; afterwards it assumes a brownish hue, but 
ultimately an indelible white depression, with minute remains 
of the cellular structure of the vesicle. 

Much reliance has been placed on the peculiar appearance 
of the cicatrization, as an indication of the vesicle having been 
of the right protecting quality ; but this has not been found to 
be so sure an indication that the system is unsusceptible to 
small-pox; for it has been ascertained that genuine vaccinia 
will sometimes leave an imperfect scar, or even no cicatrix 
whatever. This circumstance will be again referred to when 
the subject of re-vaccination is considered. 

It was the opinion of Jenner, and is now the opinion of 
practitioners generally, that some degree of sympathetic fever 
is necessary for the perfect success of vaccination, as giving 
undoubted evidence that the constitution is affected; although 
where this is absent, and the local disease has passed regularly 
through its stages, a complete immunity has existed. But the 
necessity for causing a developement of fever, by increasing 
the punctures, as has been the practice in some parts of Ger- 
many, even to the number of thirty, is altogether unnecessary, 
if not positively injurious ; for experience has shown that the 
fever, restlessness and fretfulness of the children, are greatly 
increased, even during the period of incubation ; and this 
concomitant affection will materially interfere with the pro- 
per developement of the vaccine vesicle, from the morbid 
excitement arising from simple irritation of the inflamed punc- 
tures. 

Sometimes the period of incubation is protracted for a week 
or ten days, when the vesicle makes its appearance and passes 
through its stages, affording as perfect a protection as if it had 
appeared at the usual time. A remarkable case of a protracted 
vaccination is mentioned in the Journal Universe], for July, 
1829, as having occurred in a child of three years of age. 
Four punctures were made, from which no effect resulted until 
two months afterwards, when two genuine vaccine vesicles 
were developed, from which other children were successively 
vaccinated.* This deviation is more likely to occur in winter, 
or where, from peculiarity of constitution, there exists a defi- 
ciency in the normal action of the skin. 

There are imperfect or spurious results from the insertion of 

* American Journal of the Medical Sciences, vol. vi. p. 164. 
59 



466 DISEASES OF CHILDREN. 

the virus, which may arise from various causes ; such as virus 
taken at too late a period, alteration occurring in it from partial 
decomposition from the rust of the lancet, or some peculiarity 
or disease of the individual vaccinated. 

These varieties are in some instances difficult to distinguish 
from the true vesicle of cow-pox ; but the diagnosis is necessary, 
as protection cannot be afforded by them. Dr. Willan has 
given a very accurate description of them, and has divided them 
into three varieties. # 

The first he describes as a pearl-coloured vesicle, with a 
slightly elevated dark red base. It is smaller than the genuine 
vesicle, of a globular form, flattened at the top, or -a little de- 
pressed ; the margin is neither rounded nor prominent. The 
second is the angular-edged vesicle, but in other respects bears 
a close resemblance to the true vaccine eruption. The most 
common mark of distinction is the areola, which in both these 
forms is less defined and more diffuse, of a radiated and scarlet 
colour in the second. It appears also much earlier than in the 
genuine disease, from the fifth to the eighth day alter the inser- 
tion of the virus, and continues for three days. The scab is 
completely formed at the end of this period, and soon falls off, 
leaving but a slightly marked cicatrix. The other is where the 
areola is entirely absent. 

It may be often difficult to make a close and satisfactory diag- 
nosis, in some instances, of spurious vesicles of the vaccine dis- 
ease ; but in every instance of doubt it is best to repeat the 
operation. 

As to inflammations, ulcerations, abscesses and chronic affec- 
tions of the skin, or whatever accidental occurrence may arise 
from the irritating wound, it is unnecessary to make any re- 
mark, as they cannot possibly be confounded with the genuine 
vaccine pock. 

It was formerly the custom, when there was any doubt in the 
efficacy of the vaccination, to resort to the inoculation of the 
patient with variolous matter ; but this is unnecessary, and, in- 
deed, difficult at this time to perform, when there are so few 
cases of small-pox. Revaccination will in general furnish 
proof sufficient of the condition of the system ; for if the first 
insertion has been successful, the second will be followed only 
by an erysipelatous inflammation, or by an imperfect vesicle. 
Cases, however, have occurred, where the vaccine disease has 
been developed a second time after a full and satisfactory vac- 
cination. Its success, therefore, is not always a sufficient evi- 
dence of the imperfection of the first. 

* On Vaccine Inoculation, by Robert Willan, M. D., F. R. S. ; London, 1806. 



EXCERNENT SYSTEM. 467 

Mr. Bryce* has proposed a test of the constitutional affection, 
f)y revaccinating during the progress of the vesicle, before the 
constitutional symptoms, which he regards as occurring on the 
appearance of the areola, have taken place. The method is, 
to insert the virus a second time, about the end of the fifth, or 
beginning of the sixth day after the first ; that is, from thirty-six 
to forty-eight hours before the appearance of the areola. The 
affection produced by the second vaccination will be accele- 
rated in its progress, arrive at maturity, and fade away at the 
same time as that arising from the first vaccination. If, on the 
contrary, the original vaccination have failed in producing the 
specific constitutional disorder, the second will observe a com- 
plete regular course, instead of accompanying the first, which 
it does from the fifth day, when the operation is successful. 
From this period of the second, corresponding to the tenth day 
of the first vaccination, they both proceed to their termination, 
which is usually on the thirteenth day. 

The experience of upwards forty years, accumulated from 
every part of the world, has fully proved the triumph of vacci- 
nation over the dreaded contagion of variola. The success of 
vaccination, which, from the time of Jenner, has steadily over- 
come all the obstacles which prejudice or ignorance had brought 
against it, has, however, within a few years been questioned ; 
and the recurrence of the small-pox, in some of those who were 
believed to have been guarded against its attack, has given 
rise to the idea, that a false security had been indulged in sup- 
posing they enjoyed an immunity from an attack of that disease. 
Far from drawing such an inference, from the prevalence of 
varioloid affections among those who had been subjected to the 
prophylactic measures of the immortal Jenner, a little examina- 
tion into the true facts that experience has revealed to us, will 
enable us to exhibit the subject in its proper light, and to show 
that several causes may exist to prevent the proper deve- 
lopement of the protecting disease in the system, and that far 
too much was at first expected from the influence of vaccina- 
tion by some of its early friends. While Jenner was cautious 
in his deductions, from observing that small-pox itself, in its 
most violent form, could not, in every instance, protect the in- 
dividual from a second attack, his less judicious followers boldly 
asserted that vaccination would, in every instance, afford a per- 
fect protection. 

A failure may arise from vaccinating a child at too early an 
age, before the system is sufficiently developed to render it 

* Practical Observations on the Inoculation of Cow-Pox, etc., by James Bryce, 
Member of the Royal College of Surgery, Edinburgh ; Edinburgh, 1802. 



468 DISEASES OP CHILDREN. 

liable to the full action of certain morbid conditions. Although 
small-pox attacks all ages, yet the earliest period of infancy! 
within the month, is remarkably exempt from an attack. It is 
exceedingly difficult to obtain any facts on this subject from 
medical statistics, since they embrace a wider range than would 
make them available; the diseases of the lirst period of life that 
are reported in the bills of mortality, being those occurring 
under one year, and the first months of life being never par- 
ticularized. It must, however, have been remarked by physi- 
cians, that infants under the age of a month have seldom 
exhibited a susceptibility to the contagion of small-pox, and by 
a parity of reasoning, would be also less liable to have its mo- 
dified form of vaccinia developed in the system. Children 
ought not, therefore, to be vaccinated, as is sometimes done, as 
early as the first, second or third week. 

The virus used may not be in its most perfect form, not being 
sufficiently elaborated before the eighth day, or from being taken 
at too late a period. Much difficulty formerly arose from not 
closely observing the different stages, and consequently by not 
obtaining it in its perfect state. Experience has confirmed the 
fact, that imperfect vesicles will result from virus taken be- 
fore the eighth day, and likewise after the areola has formed. 
In the last mentioned state of the vesicle the scab has made 
considerable progress, and, as Mr. Bryce observes, is pure 
lymph, desiccated, while the fluid contained beneath it is sero- 
purulent matter, the result of irritation. This is the reason 
why the dried scab is so often successful, while the fluid of the 
vesicle, at this late period, as often fails. 

Vaccination is not unfrequentiy carelessly performed, and 
very often by unprofessional persons. It should not then be a 
matter of surprise that failures take place where no care is 
bestowed on the progress of the vesicle, from which the virus 
is taken for the purpose of vaccinating. It is not unusual for 
it to be rubbed and ruptured, when irritation and inflammation, 
and a purulent matter is secreted, in connection with the proper 
virus. The scab, also, may be rubbed off, and that which fol- 
lows will be composed of desiccated, purulent matter, destitute 
of the specific character necessary to impart the disease. 

Another cause of failure may be the total deprivation of the 
vesicle of the lymph it contains, whereby the constitutional 
affection is prevented. I have seen a perfectly formed vesicle 
dry away, after having been exhausted of its lymph, without 
being surrounded by the areola, which marks the extension of 
the disease beyond the local affection. Two punctures ought 
to be made, and one allowed to pass unmolested through its 
stages. 



EXCERNENT SYSTEM. 469 

The complication of other disorders, producing great consti- 
tutional disturbance, may result in an entire failure of the pro- 
per progress of the vaccine disease. Disorders of the skin 
Jenner regarded as the greatest impediment to the proper suc- 
cess of vaccination, especially such as produced an altered se- 
cretion or humour, of whatever kind. On no account, therefore, 
except where circumstances absolutely demand it, should vac- 
cination be performed, when these cutaneous diseases exist, 
both for the purpose of securing the efficient action of the re- 
medy, and for preventing the more active developement of 
acute inflammations. Those of a chronic nature are rendered 
milder, according to general observations, but exert an unfa- 
vourable influence on the proper developement of the vaccine 
infection. The preoccupation of the skin, it would appear, by 
any disease whatever, materially affects the vaccine disease. 
Febrile action, from whatever cause, invariably modifies 
the progress of the vaccine vesicle ; so, also, will the use of 
improper diet, either stimulating or innutritious, whereby the 
vaccine disease is so modified as to impart but a partial immu- 
nity. It is difficult to obtain well ascertained facts to support 
this idea, but some instances have occurred where these would 
seem to be the preventing cause, while general analogy adds 
greatly to the testimony in its favour. Dentition, when attended 
with morbid symptoms, has an effect similar to fever arising 
from any other cause ; the punctures become inflamed, the 
disease is diverted from its natural course, and the vesicle 
exhibits its change, by the presence of purulent matter mixed 
with the lymph. 

There are certain idiosyncarcies, also, that prevent the pro- 
phylactic powers of the vaccine disease, if we may judge from 
the analogy of small-pox, where a perfect exemption is 
enjoyed by many, while others, who have exhibited deep marks 
of the pustular eruptions, have been attacked a second time. 
This fact is familiar to most physicians, and needs scarcely 
any reference for its proof. It has been mentioned by most 
writers, and instances are given in the report of the commitee 
of the Medical Society of Philadelphia on this subject, in 1828. 
The failures which have been known to take place in the 
protective powers of vaccination, have suggested the idea of 
the deterioration of the lymph, from its transmission through 
the vast numbers of individuals in the course of years, and that 
it has become necessary to restore its prophylactic powers 
by retro-vaccination. A change unquestionably has occurred 
in some instances from the pre-existence of cutaneous and other 
diseases, and from carelessness in using lymph from vesicles 
that have thus been affected in their proper developement. It 



470 DISEASES OF CHILDREN. 

is easily understood how lymph, taken without sufficient exami- 
nation as to its purity, may impart a spurious affection, which 
may be continued through a vast number of individuals with- 
out affording the desired protection. It cannot be denied 
that this carelessness has prevailed to a great degree, especially 
in country places, where it is often difficult to procure the 
genuine virus, and where the physician is unable to render 
that attention to the cases which might insure the employment 
of pure vaccine lymph on all occasions where it is required. 
It is, for the most part, considered sufficient that a vesicle is 
formed, without ascertaining the fact of its being genuine or 
spurious. An instance of this is given by Dr. W. Hooker, of 
Norwich, Connecticut,* where virus was sent to three different 
physicians, and was found by them all to be spurious, producing a 
ragged suppurating sore in the course of five or six days; and 
yet this was sent by a physician who had been vaccinating 
the inhabitants of a whole town. When thus transmitted, 
there can be no question that the human constitution has altered 
its full powers, on which its protective properties depend. 

Another instance may occur where, without any very mani- 
fest disease, a change is imparted to the qualities of the lymph, 
whereby it has become deteriorated ; a sort of latent disease 
or idiosyncracy existing, by which its qualities are altered. 
This, however, may very well be classed with the cases just 
mentioned, although not so well marked, the change appearing 
in the diminished size of the vesicle. This has been observed 
by Myer and others, who noticed that the vesicles produced 
from the stock became from year to year smaller ; from which 
it has been inferred that a gradual deterioration of the lymph in 
use has taken place. The argument would be a good one if 
borne out by facts in all cases. There are, however, a far 
greater number of instances, showing that such a general dete- 
rioration has not taken place, but that the instances cited are 
referable to other causes than the effect of the human constitu- 
tion alone, being the result of the influence of morbid changes, 
however widely extended this influence may be. Whenever 
proper precautions are used to secure the employment of pure 
lymph alone, no such alterations of its powers will take place, 
if we may judge from the appearance of the pock, and the ex- 
perience which has been afforded by a number of years in the 
use of this prophylactic remedy. The vaccine vesicle differs 
in no respect from that described forty years since ; the period 
of incubation and progress, and the distinctive marks, are the 
same now as they were then. On what ground, then, can the 

* Med. Gazette, Feb., 1835. 



EXCERNENT SYSTEM. 471 

idea be supported that it has deteriorated ? Not on that of gen- 
eral experience, for this goes directly to prove the contrary ; and 
for the occasional failures, there are, as is seen above, abundant 
and well ascertained facts, and that failures will occur in the 
variolated as well as in the vaccinated. The report of the 
committee of the Philadelphia Medical Society, before referred 
to, containing the condensed opinions of the most eminent and 
experienced physicians of that city, shows that confidence has 
not all diminished ; and that its protective powers have not 
changed, appears from the fact, that but one death from small- 
pox, in the year 1827, came to the knowledge of the committee, 
out of eighty thousand vaccinated persons, during the preva- 
lence of a most malignant and fatal small-pox. 

There then appears to be no need of resorting to the process 
of retro-vaccination to resuscitate the qualities of the impaired 
lymph ; for that in use has passed through tens of thousands, 
while the protection is as great now as it ever was. If, how- 
ever, any deterioration should occur from the causes above 
mentioned, the pure lymph may be more readily obtained by 
inoculating the cow with fresh variolous matter, and thus ob- 
tain a new stock of vaccine virus. 

Besides the deterioration of the lymph as a cause of the re- 
currence of small-pox in vaccinated individuals, it has been 
supposed by some that the influence of the vaccine disease, as 
a prophylactic, is gradually destroyed by time, and that the sys- 
tem regains its liability to be affected by the contagion of small- 
pox. The various opinions that have been advanced on this 
subject are the following : 

Mr. Brown's idea was, that the effect of the vaccine influence, 
immediately after vaccination, was a perfect protection ; that 
it gradually lost its protecting powers, until at the end of five 
or six years it requires renewal, in order to secure its prophy- 
lactic effect ; its influence, also, wearing out with the progress 
of life, and requiring periodical renewals.* 

Dr. Gregory, taking the test of his ability to revaccinate 
children as the proof of their renewed susceptibility to the 
small-pox, found that he was unable to succeed in children under 
ten years. This proof, he says, is corroborated by the fact, that 
he has not seen small-pox among the vaccinated earlier than 
ten years. His experiments, however, go to show, that the 
susceptibility to small-pox decreases in the protected after the 
age of twenty-five, f These views are also entertained by Dr. 
Leo Wolf and Dr. Mohl, of Copenhagen ; the former of whom 

* Edinburgh Medical and Surgical Journal, 1819. 
t Med. Chir. Trans., vol. xii. p. 33G. 



472 DISEASES OF CHILDREN. 

refers it to the changes which occur in the system during the 
period of puberty. 

Dr. Heim* refers it to the influence of a portion of such 
susceptibility being left unextinguished by the primary vaccina* 
tion, the process of developement influencing the capability 
of receiving the infection, and that in not a few cases this does 
not exist until some time subsequent to the birth of the child. 
Vaccination, when performed on young infants, then, is of 
little avail, but will only succeed as there is a progressive deve- 
lopement of the vaccine and variolous susceptibility. 

Dr. Thompson, from the facts before him, concluded that 
the varioloid, or modified disease, occurred at every period after 
vaccination.f 

Jenner, after a very careful examination, came to the con- 
clusion that the change effected in the constitution is not pro- 
duced by time. 

Considerable difference of opinion prevails among physicians 
of the United States on this subject; but there are not data suf- 
ficient to prove the precise time at which this change occurs, 
or what are the causes of this change. All experience, from 
the period of the adoption of vaccination to the present day, is 
in support of the fact, that time does not work a uniform change 
in the system, to the destruction of the prophylactic powers of 
the vaccine virus. If it were so, we should often see the 
aged attacked with the variolous disease. That the period of 
puberty produces a temporary susceptibility, would seem to be 
true, for the greatest number of cases of varioloid occurs, it 
is well known, between the ages of fourteen and twenty-five. 

From the extreme difficulty of ascertaining whether an in- 
dividual has been properly vaccinated ; from the influence 
also of morbid action in the system at the time, interfering 
with the proper progress of the constitutional affection ; or 
from the peculiar idiosyncracy of the patient, whereby a second 
attack may occur, it is the safest practice to resort to re- 
vaccination whenever small-pox prevails very extensively, or 
with unusual malignaacy. It will not be out of place here to 
exhibit briefly a few facts in proof of the triumph of vaccina- 
tion, in addition to the mass of evidence which has accumu- 
lated beyond parallel in any other department of scientific 
investigation. 

Before the discovery of cow-pock, it was computed that 
forty thousand persons died annually in Great Britain and Ire- 
land, and that fifteen millions of people were carried off by it 

* Quoted in the British and Foreign Medical Review, for January, 1839. 
t Op. Cit, 



EXCERNENT SYSTEM. 473 

in Europe, in twenty-five years, according to the statistics of 
Sir Gilbert Blane,* the average number of deaths in London, 
for a period of forty-five years next preceding the introduction 
of vaccination, was 86 in 1,000 ; the number in the last fifteen 
years of this period, 90 in 1,000. After the introduction of 
vaccination, from the year 1804 to 1818, the deaths from 
small-pox were found to be in the proportion of 53 in 1,000. 

In the kingdom of Sweden, from 15,000 persons who were 
destroyed from small-pox in the year 1779, the number was 
reduced to 37 in the year 1823. f The greatest reduction took 
place shortly after the introduction of vaccination, after the 
year 1801. These statements might be followed by nume- 
rous others from the different kingdoms and cities of Europe. 

There is no question that our own country would furnish a 
similar exhibition of facts, could we but have the opportunity 
of availing ourselves of statistical records as in other coun- 
tries. These, however, have been kept on a very limited 
scale, and official returns of deaths in our large cities and ex- 
tended districts of territory have been made but comparatively 
a few years back. By comparing the effects of small-pox, 
where vaccination was not in use, with the present day, our 
country also exhibits in a striking light the benefits resulting 
from vaccination. 

The early history of America contains some accounts of the 
ravages of small-pox among the Indians ; they are but mere frag- 
ments, but are sufficient to show its frightful mortality. It pre- 
vailed among the Iroquois with great severity in 1663, as re- 
lated by Charlevoix. J He does not give the number destroy- 
ed in this pestilence ; but in a subsequent one, in 1670, near 
Trois Rivieres, he states that 1,500 were attacked, and not one 
recovered.|| Other early travellers also mention the extensive 
fatality of small-pox. 

Dr. Douglass, in an essay published upwards of a century 
ago in Boston.§ states that "in the year 1721 we had in Bos- 
ton 5,989 ill of the small-pox, whereof died 844 ; of these, up- 
wards of 80 died with purple spots and hemorrhages, whereof 
65 came to my knowledge." "The small-pox," he remarks, 
"rendered the large and populous town of Boston a mere hos- 
pital." All these cases, it is represented, were of the greatest 
malignancy, with bloody urine, " bloody spittle," and hemorrhage 



* Med. Chirurg. Trans., vol. x. 
t Evanson and Maunsell, p. 252, Amer. edit. 
t Hist, et Descript. Gen. de la Nouvelle France, vol. i. p. 378. 
II lb. vol. ii. p. 428. 

§ A Practical Essay concerning the Small-Pox, by William Douglass, M. D.; 
Boston, 1730. 

60 



474 DISEASES OF CHILDREN. 

from every part, and some dying, " wallowing in their blood.' 
No age nor sex was exempted from it in its worst form. Adults 
of 60 years, and infants of six months, were alike carried off by 
" purples and hemorrhages."* 

The more accurate accounts furnished of late years, exhibit 
a truly frightful picture of the ravages of small-pox in the re- 
mote region of the west ; the whole country through which it 
passed, the Upper Missouri, in the year 1837. being literally 
depopulated. The following is the summary of this pestilence 
from one near the spot.f The Mandan tribe had been reduced 
from 1,600 to 31. The Gros Ventres, or Mintarees, a tribe 
numbering 1,000, took the disease about a month later than their 
neighbours, the Mandans ; one half had already perished at the 
time of writing the letter, and the disease was still increasing ; 
they doubtless shared the same fate as the Mandans. The 
Ricarees, 3,000 in number, were also attacked, and not one in 
50 recovered. The Assinniboins, 10,000 strong, and the Crees, 
numbering about 3.000, have been almost annihilated; and of 
the Black Feet Indians of the Rocky Mountains, one tribe, 
consisting of 1,000, it was ascertained, had been entirely ex- 
terminated. 

Small-pox in New- York, in the year 1815, Was so virulent as 
to attack almost every individual in whom the susceptibility 
had not been destroyed by vaccination. The proportion of 
deaths from the confluent kind, in the opinion of the committee 
of the Medical Society, appointed for the purpose of inquiring 
into the efficacy of vaccination, was greater than was ever 
observed in London, or on the Continent of Europe. J Of 254 
deaths from small-pox, recorded in the city inspector's register, 
somewhat more than one third were of the confluent kind. 
With such facts of the virulence of the disease, what would 
have been the condition of the city had the ravages of the dis-> 
ease not been controlled? Judging from what has heretofore 
occurred, every dwelling would have been literally a loathsome 
hospital, and every surviving inhabitant a terror-stricken 
mourner. 



* The following passage occurs in a public address, delivered at Boston in the 
year 1698. " The angels of death have often shot their arrows of death into the 
midst of the town ; the small-pox has especially, four times, been a great plague 
upon us. How often have there been bills, desiring the prayers for more than 
one hundred sick in one day, in one of our assemblies. In one twelvemonth, 
about one thousand of our neighbours have, one way or another, been carried to their 
long home." Magnolia Christi Americana, or the Ecles. Hist, of N. E., by the 
Rev. Cotton Mather ; London, 1702. 

t Letter from Major Pitcher, TJ. S. A., dated St. Louis, Feb. 27th, 1838. 
Published in the journals of the day. 

t Report of the Medical Society of the City and County of New- York, 1816. 



EXCERNENT SYSTEM. 475 

The number of deaths in New- York from small-pox, since 
the year 1805, a period of thirty-five years, is a trifle over 
3,000 ; in some of the later years of this period the number 
has increased, yet the comparative number is less than at the 
commencement of the term, when the population was about 
two thirds less than it is now. In some of the years there is 
no report of deaths from this cause ; and the proportion in the 
period of five years, when it prevailed most, exhibits less than 
26 deaths in 1,000. 

The following calculation exhibits the proportion of deaths 
in the city of New- York, in every thousand, from the year 
1805, when the reports were first made, to the end of the year 
1840. During the first period of five years the number was 
26 in 1,000 ; in the second period, 14 ; in the third, 23 ; in the 
fourth, about 25; in the fifth, 18 ; in the sixth, 21, and in the 
seventh, at the close of 1840, 21. That the mortality has not 
been greater, is a matter which would naturally create some 
surprise, when it is considered that the number of emigrants 
has greatly increased within a few years, among whom the 
disease prevails with great severity. Vaccination being uni- 
versally adopted by the permanent inhabitants of the city, they 
are by no means the class among whom the disease prevails; 
but it spends its violence among the transient emigrant popu- 
lation, where vaccination, it is fair to suppose, has been neglect- 
ed ; for when questioned on this subject, they often give no 
satisfactory answer. 

Philadelphia, according to calculations made from the public 
statistics, exhibits rather less than 21 in every 1000 deaths 
from small-pox, during a period of twenty years; and although 
in some years corresponding to those in which the disease pre- 
vailed with more than usual malignancy in New- York, there 
was a considerable increase in the actual number of deaths, 
yet they bore the same proportion to the inhabitants as in the 
latter city. 

Small-pox, it was remarked, prevailed during a few years 
with great severity, and the comparatively small number of 
deaths is an evidence of the protective power of the vaccine 
disease. Every variety, from the mildest varioloid to the most 
fatal confluent form, was to be found existing simultaneously — 
the former, among those in whom the susceptibility had been 
partially destroyed, either by a previous attack, or by vacci- 
nation, and the latter, among those who had never been pro- 
tected ; all being equally exposed to the action of a high degree 
of contagion. 

Similar results have been found in other cities of the Union, 
proving that the benefits of vaccination are to be seen mostly 



476 DISEASES OP CHILDREN. 

in the immense saving of human life, and not in the universal 
exemption of every individual vaccinated, from an attack of 
small-pox, when exposed to a highly malignant contagion. 
This exemption does not exist in every instance, after an attack 
of small-pox itself; and individuals, with the most unequivocal 
evidences of having had the disease, have been again attacked, 
and have died, where it has prevailed with great severity. 

The full benefits of vaccination are not to be found by seek- 
ing for them indiscriminately among the inhabitants of large 
cities, who are constantly exposed to the numerous causes 
which produce failure in the progress of the vaccine vesicle, 
but among those who enjoy all the benefits of professional skill, 
not only in the selection of proper virus, but also in ascertain- 
ing the proper developement of the constitutional symptoms. 
We might, therefore, expect to find it in its most perfect state 
where these requisites are enforced, as in public institutions, 
and wherever the necessary measures are fully adopted. The 
following are a few of the results obtained from these sources. 

In the year 1815, the small-pox appeared on board the U. S. 
Frigate Guerriere. An inquiry was instituted by the surgeon, 
to ascertain whether those attacked had ever been vaccinated, 
when it was ascertained that none of them had ever had it. 
Not one of the crew who had been vaccinated took the disease 
in any form.* 

In the different institutions for the reception of children, the 
greatest care is bestowed on the details of vaccination, and it 
is under such circumstances that we are to look for the full re- 
sults of this important preventive measure, up to the age of 
fourteen years, the average period at which the children are 
discharged. 

In the Orphan Asylum of Charleston, S. C, which in the 
year 1829 contained one hundred and fifty children, not a sin- 
gle case of small-pox or varioloid occurred during the preva- 
lence of that disease, although no additional restriction was 
imposed upon their intercourse with the citizens. f 

The aggregate number of children received into the different 
Orphan Asylums of Philadelphia, since their establishment to 
the beginning of the year 1841, is 1,009, and among the whole, 
there has been but one death from small-pox ; this occurred 
some years since, out of sixty-five cases of the disease. The 
children were carefully examined, both with reference to the 
virulence of the affection, and to their condition at the time of 



* Report of the Med. Soc. of N. Y., 1817. 

t Report of the Committee of the Board of Health of Charleston, etc. ; Amer. 
Journ. Med. Sciences, November, 1831. 



EXCERNENT SYSTEM. 477 

the attack. Ten were without the usual cicatrix left by the 
vaccine vesicle, and the child that died was one of the number 
destitute of this mark. 

In the city of New- York, the total number received in all the 
orphan asylums, is 2,384; and although the small-pox appeared 
in two or three of them, yet it was in a greatly modified form, 
and no deaths have occurred from this cause. A similar result 
is obtained, also, from the House of Refuge, which exhibits an 
aggregate number of 2,657 children, received during sixteen 
years. The whole number, therefore, that have been inmates 
of these various institutions in the city of New-York, is 5,041, 
and not a single death from small-pox has at any time occurred. 

Baltimore, also, presents the like return, out of 3,500 children 
that have been for several years in the alms-house and differ- 
ent orphan asylums of that city. 

The entire number of children, therefore, that have been under 
the care of the above mentioned institutions, since their establish- 
ment, is 9,550, and but one death has occurred from small-pox 
in the course of thirty years ; and this one it is fair to presume 
had not been vaccinated, as no mark of this operation was 
found after the most careful examination. 

The results of vaccination thus ascertained, cannot be fol- 
lowed after the children have left these institutions, but up to 
that time the benefits may be learned by comparing with them 
the effects of small-pox before the introduction of vaccination ; 
its ravages being principally among the young. At this day, 
also, the small-pox is more prevalent and fatal among children ; 
as appears from the city inspector's report of deaths in the 
city of New- York, for the last few years. Ninety-one deaths are 
reported to have occurred from this cause, in the year 1838 ; 
69 of these were children under ten years; and in 1839, 68 
deaths were reported, 45 of which were among children of 
the same ages ; and of 231 deaths from the same cause in 
the year 1840, 131 were also children not yet arrived at the age 
of ten years. To whatever cause this number of deaths is to 
be attributed, whether to an imperfect vaccination, or its neg- 
lect altogether, the comparison shows the triumphant results 
of the prophylactic measure now universally adopted. 

The value of the discovery of vaccination, as was before 
remarked, does not consist in its entirely preventing an attack 
of small-pox, but in disarming it of its terrors—in reducing 
the mortality, which it has been seen makes it one of the most 
fatal scourges of mankind, to a very small amount ; a result 
not obtained even by the small-pox itself, many more deaths 
having, as has been sometimes observed, occurred among in- 
dividuals after having passed through that disease, than among 



476 DISEASES OP CHILDREN. 

those who had been protected by vaccination. The recorded 
statistics of Drs. Mitchell and Bell, of the result of their expe- 
rience during the epidemic of Philadelphia, in 1823 and 1824, 
also prove this fact, which has been noticed by others. Of 248 
cases of small-pox and varioloid, 155 were unprotected, of 
whom 85 died ; 64 vaccinated, of whom 1 died ; 9 inoculated, 
of whom 3 died; 7 previous small pox, of whom 3 died ; 13 
unknown ; no deaths.* 

When these results of the two methods are considered, how 
striking are the advantages of vaccination, not only in saving 
human life, but also in its direct tendency to exterminate that 
loathsome malady altogether ; and when the many causes which 
are known to exist that influence, the proper developement of 
the vaccine disease, and the carelessness which must prevail 
in the thousands of instances of vaccination, are taken into 
account, far from having our confidence lessened when the 
results do not accord with our most sanguine wishes, these 
circumstances should on the contrary strengthen our faith in 
the salutary influence of a remedy, which still must be regard- 
ed as one of the greatest blessings to man. 

SYPHILIS. 

Syphilitic affections sometimes occur in infants, transmitted 
either from the mother to the foetus, or communicated during 
the passage of the child at birth, from venereal ulcers, or from 
the nipples of an affected nurse. 

Although the hereditary transmission of syphilis has been de- 
nied by some, the numerous facts on record unequivocally set- 
tle the question of the congenital origin of syphilitic eruptions. 
Hunter gives the case of a woman who was covered with ve- 
nereal pustules, giving birth to twins, who likewise had similar 
pustules on their bodies.f Mr. Bell mentions the fact of his 
having seen many infants at birth thus affected, without any 
external marks of the disease on the parents.J and a number of 
cases are cited by Rayer, from Schenk, Rosen, Swediaur and 
Mahon. Dr. Brown, in the Cyclopaedia of Practical Medicine, 
gives a similar fact. Dr. J. W. Francis, in a note in the third 
edition of Denman's Midwifery, mentions the fact of three in- 
stances having come under his observation. A remarkable 
case of the transmission of syphilis to the offspring is recorded 
by Dr. H. D. Bulkley, in an able article on the syphilis of in- 
fants,|| where the father, after having been to appearance cured 

* N. A. Med. and Surg, Journ., vol. ii. 

+ Hunter on the Venereal; London, 1776. 

t Treatise on Gonorrhoea and Lues Venerea, by Benjamin Bell, p. 259. 

H The New- York Journal of Medicine and Surgery, for October, 1840. 



EXCERNENT SYSTEiM. 479 

of a venereal affection for four years, married, and the child, 
that was born at seven months, exhibited the usual symptoms of 
syphilitic disease. From these and numerous other similar facts, 
it is evident, that either one or other of the parents is affected 
with the syphilitic poison at the time of conception, although 
presenting no external marks of the disease. This is evident 
from the child being affected with the disease, traceable to no 
other source. Several children have also been successively 
born covered with syphilitic eruptions ; or miscarriages or pre- 
mature birth have occurred, where the bodies of the foetuses 
have been in a similar state. The last is not an uncommon 
event about the sixth or seventh month, and is so frequent as 
to be regarded as one of the causes of abortion. 

It is not every eruption on the body of a new born child, for 
the production of which a syphilitic cause is supposed to exist, 
that is to be regarded as a disease of this nature. New-born 
children have often been seen covered with vesicles and ulcera- 
tions bearing the appearance of venereal sores, but which dis- 
appear of themselves. Such cases M. Billard has met with at 
the Foundling Hospital at Paris, and regards them as a species 
of eczema. A species also of pemphigus bears a close re- 
semblance to the lues of infants, while psoriasis, some forms of 
rupia, impetigo, and other ulcerations, may be mistaken for it. 
But notwithstanding the numerous errors which may arise from 
mistaking these morbid conditions of the skin, no doubt can 
remain of the congenital transmission of true lues. The fact of 
nurses having had the venereal disease, exhibiting its true charac- 
ters developed in them through the medium of the nipple, and in 
their turn communicating the disease to their offspring in its most 
unequivocal form, sufficiently establish the fact. Dr. Bulkley, 
in the paper before referred to, mentions the case of a female 
who was affected with unequivocal symptoms of secondary dis- 
ease derived from a sucking child, and who was delivered of a 
dead child from this cause, and afterwards of two living children 
with the marks of syphilitic disease, which was afterwards con- 
veyed to another perfectly healthy nurse by one of them. 
An instance of two nurses being successively infected with the 
venereal disease in this manner is given by Bell.* 

These circumstances, in connection with the fact of the pre- 
vious existence of the disease in either of the parents, and the 
effects of remedies, sufficiently establish the nature of the affec- 
tion. 

The child may also receive the infection during its passage, 
from the external parts, on which there exist syphilitic ulcers. 

* Op. Cit. p. 260. 



480 DISEASES OF CHILDREN. 

Under these circumstances the disease is more likely to appear 
about the eyes, lips, or genital organs ; parts which possess 
greater vascularity than other external parts of the body. It 
is the opinion of some that the thick secretion covering the skin 
of a new born infant prevents the manifestation of the disease 
on the general cutaneous surface. 

The communication by means of a nurse is by no means un- 
common, although, according to the opinion of some, it does 
not occur except in those cases in which the nipples are dis- 
eased, as Hunter, Girtanner, and others. Gardien entertains a 
different opinion on this subject, and considers the milk to pos- 
sess infectious qualities. 

Children born with the syphilitic disease are remarkably de- 
licate, whether premature or otherwise, with a general appear- 
ance of debility, all the muscles being soft and shrunken. In 
some, the whole aspect is that of an aged person. When an 
infant is born with the external marks of the disease, they are 
in the form of an erysipelatous eruption in some parts of the 
body, while in others the cuticle is destroyed. The nails on the 
fingers and toes have been also wanting. This eruption has 
a copper-coloured appearance, and its character may be strongly 
suspected when there is evidence of a syphilitic taint in the 
parents, or when, from their history, such affection has pre- 
viously existed. 

The child sometimes will not exhibit any signs of the dis- 
ease until an indefinite time after birth, but usually from four- 
teen days to two months after birth ; in some instances not until 
three months. When delayed beyond six weeks or two 
months, it is generally developed by the existence of some other 
excitement in the system, as vaccination, dentition, or the 
changes which occur on weaning. In twenty-eight cases occur- 
ring to Dr. Bulkley, " the symptoms first appeared at the end 
of a month in nine cases ; between one and two months in six ; 
between two and three months in six ; between three and six 
months in two ; between six and twelve months in three ; at or 
about twelve months in two ; so that of the twenty-eight cases, 
twenty-one appeared at or before the end of the third month." 

The disease usually shows itself first in the skin, generally 
about the nates and pudendum, in the form of irregular blotches, 
of a colour varying from that imparted by the stain of a straw- 
berry, to the copper colour so commonly described as the pecu- 
liar aspect of syphilitic eruptions. These blotches are slightly 
raised from the level of the skin, forming elevated ulcers on the 
nates, neck and shoulders. On the face they quickly become 
covered with scales or scabs. The eruption assumes different 
characters, being in some instances, and in different stages of 



EXCERNENT SYSTEM. 481 

the disease, spots or patches, pustules, tubercles, excoriations 
and ulcers. 

As the disease advances, the various tissues and parts become 
affected, and exhibit a combination of symptoms, both charac- 
teristic of the extent of the infection, and of the general debility 
and extreme loathsomeness of the wretched infant. The ema- 
ciation is extreme ; the cachectic appearance of the whole of 
the skin marks the universal operation of the poisonous prin- 
ciple. The skin is generally of a brown or copper colour in 
the intervals of the scabs ; the lips are swelled and deeply 
fissured, and aphthae appear in the mouth. The voice is shrill 
and feeble ; the breathing is difficult through the nose, produ- 
cing the well known sound of snuffles. This last symptom often 
precedes the cutaneous eruption, and is followed by a discharge 
of yellow inspissated mucus from the nases. 

The history of this affection will greatly assist in its diagno- 
sis ; but this may be at times difficult to ascertain with any 
degree of accuracy ; indeed, the necessity of great circum- 
spection in our inquiries will sometimes preclude the obtaining 
of sufficient data from this source. The character of the 
eruption, its obstinacy under other treatment than that usually 
resorted to in the management of syphilis, will generally excite 
a suspicion as to its nature. The whole appearance of an 
infant infected with syphilitic poison is so characteristic, differ- 
ing so essentially from the appearance in any other disease, 
but difficult of description, that even one not familiar with it will 
be struck with the remarkable and unusual physiognomy. 
The itch occasionally becomes very severe, and degenerates 
into obstinate ulcers : these, however, are of a more pustular 
character than the condylomatous ulcers of syphilis, and are 
accompanied with severe itching. In connection with the his- 
tory of the affection in the parents, is the occurrence of abortions, 
with the cutaneous affection above described. Where a living 
child has been brought into the world with an eruption, but 
little doubt can exist as to its nature. 

Syphilis, when early subjected to medical treatment, is not 
a disease of danger ; and the prognosis may, for the most part, 
be favourable. 

Treatment. — The preventive treatment, by the administra- 
tion of suitable medicine to the parents, is that which has been 
recommended where there is undoubted evidence of syphilitic 
disease in them ; or where, from the occurrence of the birth of 
children affected with it, the syphilitic taint exists without its 
external manifestation. Where both have previously been 
affected, they should both be brought under the mercurial and 
alterative course. This plan, however, often fails of producing 

61 



482 dls eases or children. 

the desired effect ; but as it has in some instances succeeded, 
it is best to adopt the safest course, and administer alteratives 
to one or both parents. Sometimes the infection takes place 
during utero-gestation. It will, under these circumstances, be 
necessary to administer mercury to the mother as soon as the 
affection is ascertained. No doubt can now exist on this 
point, although many have objected to the giving of mercury 
to pregnant women. The decided advantages both to the 
mother and offspring more than counterbalance any bad effects 
which may arise from its use. The other preventive measures 
are, preventing the child from coming in contact with the syphi- 
litic ulcers, by freely anointing the diseased part with lard, and 
causing the child to be carefully washed immediately after its 
birth. 

Mercury must, in most cases, be given directly to the child, 
as the only method to be relied on for the perfect eradication 
of the disease. Most practitioners bear evidence to the advan- 
tages children derive from the administration of mercury in 
this disease, and to the little constitutional irritation following 
its use when judiciously administered. The most eligible form 
in which it can be given, is the hydrargyrum cum creta, a grain 
or two twice a day, until an alteration in the eruption begins 
to appear, when it may be suspended for a few days and then 
resumed, if the syphilitic symptoms do not evidently lessen. 
A quarter of a grain of calomel, mixed with sugar, is also a 
good form of administering mercury. The blue pill, as pos- 
sessing less irritating qualities, may also be advantageously 
used in infants, mixed up with syrup. The bi-chloride of mer- 
cury is useful for children ; it is easily given, in the dose of one 
twentieth to one twelfth of a grain, and it is said by some to 
be more prompt in removing the disease than any other prepa- 
ration. Dr. Cogswell, in his essay on iodine, speaks of the 
good effects of the proto-iodide of mercury in syphilis of 
children, especially in the cutaneous affection; and other practi- 
tioners prefer it before any other preparation of mercury.* The 
annexed formula is that which was employed by Ricard.f 
Whatever preparation of mercury is used, the syrup of sarsa- 
parilla ought to be combined, and the warm bath frequently 
used. Tonics, good diet, and pure air, will very materially 
aid in effecting a cure in feeble children. Bitter infusion, or a 

* La Lancette, 1834. 

t # Hydr. Proto-Ioduret, gr. vi. 

Extr. Opii., gr. iv. 

Lactucarii, gr. xxiv. 

Ext. Guiac, gr. xlviij. 
One pill for a child a year old. 






EXCERNEXT SYSTEM. 483 

weak solution of sulphate of quinine, will greatly assist the 
specific action of mercury in debilitated children, when it has 
been continued for some time without any marked alteration. 
The bowels are sometimes brought into an irritable condition 
by the continued use of mercurials, and a diarrhoea will arise ; 
this may be controlled by a small dose of tincture of opium, or 
by combining minute portions of Dover's powder with the 
mercurial. The latter is decidedly preferable, from its action 
on the skin, and the secretion which it excites in the emunctories. 

Under this course, about two or three months will be required 
for the removal of the disease ; but upon its disappearance 
the use of medicine must not be discontinued, as it is no unusual 
circumstance for the affection to re-appear ; when it will 
become necessary again to resort to a mercurial cause. 

Local applications are necessary for the proper manage- 
ment of this disease; and the black wash, yellow wash, and 
ointment of the different preparations of mercury, are all use- 
ful applications to the several ulcers. To those that exhibit an 
indolent appearance, the sulphate of copper or nitrate of silver 
must be used, while narcotic emollient fomentations will be 
found useful in painfully excoriated parts. Constant ablutions 
must be used throughout the whole course of the treatment. 

While attention is thus bestowed on the child, the mother or 
nurse should not be neglected, as the affection of her system 
becomes necessary where the disease is of any obstinacy ; and 
an evident change in all the symptoms will quickly appear 
when the proper remedies for lues are given to her. Altera- 
tives, such as the decoction of the woods, are advised for her, 
where the syphilitic disease is not apparent ; but mercury 
should in all cases be given, where there is any evident syphilitic 
disease existing. 

SCABIES. 

This is a well-known inflammatory and contagious affection 
of the skin, characterized by a vesicular eruption, attended with 
a violent itching, from which it receives the name of itch. 
The vesicles are transparent at their summits, and contain a 
viscid fluid of a serous nature. These eruptions appear in 
every part of the body, but always at first in those parts which 
are placed in contact with the disease in others. Hence it 
more often shows itself in the hands, and on the breech of 
sucking infants, parts which are the most commonly brought 
into contact with the hands of those affected with this disorder. 

Etiology. — It is unquestionably a contagious disease, never 
being produced in any other manner. There are some patho- 



484 DISEASES OP CHILDREN. 

logists, Fabricius, Hildanus, Pringle and others, who assert 
that the itch may be produced spontaneously, under peculiar 
circumstances, and that it occurs as a crisis of another affec- 
tion; but the frequent complications of the various cutaneous 
disorders may often render a perfect diagnosis obscure and 
difficult, and it may be that other vesicular and papular erup- 
tions have been mistaken for this disease. Where an affection 
is so uniformly contagious, and according to all observation, 
only traceable from one affected person by contact to another, 
by the most unequivocal evidence, the idea of its spontaneous 
origin may be questioned. Whatever may be said of infectious 
diseases, sometimes originating in this manner, and afterwards, 
through the changes in the atmosphere, becoming communica- 
ble, such can scarcely be proved with regard to the itch, which 
uniformly requires the contact of parts for its transmission. 

The itch is more perfectly contagious than any disease 
known; for it is communicated with almost complete certainty 
on the slightest contact with the morbid secretions from the 
vesicles of those affected with it, at all times and at every age. 
When several children are crowded together with the disease 
once introduced, it invariably spreads through them all, and is 
propagated more by contact and by want of cleanliness, than 
by any causes arising from climate or the season of the year. 

It has long been maintained that this affection was produced 
by a small insect, nearly invisible to the naked eye ; and a figure 
was even given of it in the Theatrum Insectorum of Moufet. 
Hauptman also published a drawing of it from nature ; but a 
complete description is given by M. Raspail* and M. Gas,f who 
have, with great patience and industry, succeeded in their inves- 
tigations, both in ascertaining the form of the insect, of which 
the former has given a complete and faithful account, and also 
in investigating its habits with no less ability and zeal ; detect- 
ing the insect itself in the formation of the first vesicle, or tracing 
it as it burrowed beneath the cuticle. On one occasion the insect 
took twenty days in burrowing two lines, and another performed 
the same amount of labour in three days. It is exceedingly 
minute, of a white colour, and may, without the aid of a micro- 
scope, be seen on a coloured surface. 

Treatment. — The only treatment necessary, in recent and 
uncomplicated cases, is of a local nature ; the destruction of the 
insect is always followed by a cure of the disease. It has been 
observed by Dr. Willis, in the appendix to Raver's work on the 
Diseases of the Skin, that the insect is never found alive after 

* Mem. Compar. sur l'Histoire Nat. de Fins, de la Gale; Paris, 1834. 

t Recherches sur FAcarus on Scarcopte de la Galede FHomme; Paris, 1834. 



EXCERNENT SYSTEM. 485 

the patient has been subjected for three or four days to the ordi- 
nary treatment. The most efficacious is the sulphur ointment 
alone,* or combined with the sub-carbonate of potash. f About 
one ounce of the former should be used daily, by rubbing it 
over every affected part, and about half that quantity three 
times a day, for a child eight or ten years of age. A quarter of 
an hour should be spent in its application, first being careful to 
wash the body well with soap and water, which should also 
follow each application. This course will almost invariably 
cure the disease in three or four days. 

In long standing cases it may be necessary to resort to other 
measures ; for from the violent inflammation of the skin and the 
crowded state of the vesicles, frictions, in the manner above 
mentioned, may not be admissible. Under these circumstances 
sulphurous baths are the most easy and efficient remedies. 
These baths are particularly useful in children. When they can- 
not be had, artificial washes may be used. The annexed is the 
lotion of Alibert.J It may be somewhat varied for children. 
The sulphurous soap liniment of the Hopital des Enfans is also 
a good application in obstinate cases. || 

* ~fy Sulphur. Sublim., gij. II ^ Potassae Sulphuret, 



Adeps. Suil., §iv. M. 
t fy Sulphur. Sublim., 3ij. 

Potassee Sub. Carb., 5j. 

Adeps. Suil., §j. M. 
t fy Potassae Sulphuret, 

Acidi Hydrocynic, aa. §j. 

Aquae, ftiij. M. 
An ounce of this may be added to four 
ounces of warm water, and the diseased 
pans washed with the mixture. 



Saponis Hisp., ft>ij. 
01. Olivar., ftij. 
01. Origan., 3ij. 

The sulphuret of potash to be first dis- 
solved in one third of its weight of wa- 
ter; the soap then to be dissolved in a 
sufficient quantity of water to form a bath, 
and the oil added by degrees ; the solution 
of potash is then to be added to the whole. 



ANIMAL FUNCTIONS. 



NERVOUS SYSTEM. 

PECULIARITIES OF THE NERVOUS SYSTEM. 

The usual division of the nervous system is that of the cere- 
bral and ganglionic ; the former connected with the animal, 
the latter with the vegetative life. The cerebral, or cerebro- 
spinal apparatus, has its origin in the medulla spinalis ; for as 
early as the fourth or fifth week of the foetal existence, the me- 
dulla oblongata is distinctly seen, while the spinal marrow is 
also traced in the form of two white threads. It is not until 
the seventh week that the cerebellum is first discovered. The 
whole, therefore, of the cerebral mass is a production of the 
spinal marrow, as the different parts can be traced in their 
process of developement.* 

The internal or central part of the nervous system, compri- 
sing the spinal marrow and encephalon, is larger in an infant 
in proportion to the body. The latter, especially, continues 
much larger in proportion, until between six and seven years, 
when it has acquired the weight which continues throughout 
life. 

During the period of developement in the foetus, there is no- 
thing so remarkable as the change of form in the different parts, 
as they are not the same parts in miniature, but gradual and 
successive alterations. These alterations, however, do not 
come within the limits here allotted to the subject, which is 
only the consideration of the nature and operations of the ner- 
vous system from the period of birth. 

The interna] surface of the spinal marrow is in early life con- 
tinuous with the external, as the entire canal is much larger, 
and its surfaces much more uniform than in advanced life. 

The proportion between the spinal marrow and the cerebrum 
is as one to one hundred and seven in the full grown foetus and 
the child of five months, although the actual volume of both 
in the latter is three times as great as the former ; in the adult 
the proportion is as one to forty. 

* Anatomie du Cerveau, etc.: from the German of Tiedemann. Translated into 
French by N. G. L. Jourdan; Paris, 1823. Serres, Anatom. Compared. Meckel. 



NERVOUS SYSTEM. 487 

The medulla oblongata, in its different parts, is much more 
developed in early life than at a later period, especially in its 
lower anterior portion. It is therefore more distinct than the 
spinal marrow. 

The cerebellum is the latest developed of all the parts of the 
central mass of the nervous system. At birth its proportion to 
the cerebrum is as one to twenty-three, the cerebrum weighing 
about nine or ten ounces, and the cerebellum about three 
drachms and a half. It grows very rapidly, so that in one 
month its proportion is as one to seventeen, and at six months 
as one to eight ; when its weight is about two ounces. It in- 
creases remarkably in size about the period of puberty. 

The cerebrum is at first large in size, but imperfect in struc- 
ture ; it is a soft semi-fluid substance, and evidently less ad- 
vanced in structure than the medulla oblongata or medulla spi- 
nalis. Although at the time of birth it has the general form of 
an adult's brain, yet it differs much in its appearance as well as 
in its consistency. It is white, with very little well-marked 
distinction between the cineritious and medullary matter, and 
the appearance denominated the centrum ovale does not exist 
on cutting through the hemispheres, as in the adult. On a close 
examination, the boundaries of the cortical substance may be 
detected in the form of a line passing over the superficies of the 
brain. There are a number of vessels ramifying through it at 
the age of six or eight months, which imparts to it at that pe- 
riod a reddish tint, rendering the distinction between the cine- 
ritious and medullary portion difficult to distinguish. 

In the early period, as was before remarked, the appearance 
of the brain, when cut, is white. In this respect, and as to its 
consistency, it bears a close resemblance to the article of con- 
fectionary denominated blanc mange. It does not alter much 
in consistency until about the seventh year, when its density 
and weight are about the same as in the adult. 

The exact alterations which the brain undergoes have not 
been ascertained with any tolerable degree of accuracy ; they 
however appear to take place before the ninth month, when the 
gray substance exhibits a reddish appearance, showing an in- 
crease of vascularity and an exaltation of its vital energy. This 
change, it has been remarked, occurs in those parts nearest to 
the medulla oblongata, according to the order of developement. 
From this period the brain advances remarkably in its com- 
plete organization ; it is then that the signs of intelligence are 
first displayed. Its consistency becomes much firmer, and the 
medullary and cortical portions more evident, while its convo- 
lutions are more defined. These increase in distinctness, and 
about the seventh year the whole presents the firmness and 



488 DISEASES OF CHILDREN. 

arrangement of the adult. At this time, also, the pineal glands 
exhibit the first appearance of the concretions which are usu- 
ally found in them. 

The changes of the brain, and the increase of size of that 
organ, seem to require some peculiarity in the arrangement of 
its coverings ; we consequently find the bones of the skull in an 
imperfect state of ossification, whereby a change in the size of 
the brain may take place, without subjecting it to compression. 
The bones composing the cranium are not united by the satures 
which are found in the adult, but are entirely separated, while 
several deficiencies exist in different parts of the skull. 

These openings, or fontanelles, are six in number; the largest, 
on the top of the head, is called the bregma, and is formed by 
the deficiencies which exist at the place where the parietal 
bones and the frontal bone afterwards unite. Another is 
situated at the posterior part of the head, between the parietal 
and occipital bones ; and two on each side, the one in the tem- 
poral fossa, and the other above the mastoid process. 

All these openings gradually close as the ossification of the 
bones advances ; and about the fifth year the satures are all 
united, and the entire cranium exhibits the same condition as in 
the adult state. The size of the head varies, and its shape also is 
different in different individuals, for there exists not unfrequently 
a marked variation with respect to the relative proportions of 
the regions of the brain. 

The movements of the brain are easily seen in the infant, 
particularly in the anterior fontanelle or bregma. There are 
two, clearly marked ; the one depending on the action of the 
arteries, the other arising from the act of respiration ; the last 
mentioned movement is less frequent than the first. When the 
hand is placed over the opening in the skull, the parts beneath 
are found to rise and fall, which, when owing to the respiratory 
process, is produced by the alternate expansion and contraction 
of the encephalon. 

The membranes covering the brain are much more vascular 
in early life than at a later period. A larger quantity of fluid 
exists between the arachnoid and the other membranes, and 
also in the cavities, than in after life. The glands of Pacchioni 
do not in general exist in children. The dura mater is much 
thinner than in the adult, and its adhesion is less firm. 

The brain being in a very imperfect state of organization at 
the commencement of life, the peculiar functions of this organ 
do not exist, and a new-born child is even devoid of ordinary 
perception. 

For the first nine or twelve months the brain is in an active 
state of developement, and passes through the various changes 



NERVOUS SYSTEM. 489 

necessary to its perfect formation. An increased quantity of 
blood, therefore, becomes necessary for the transition of this 
organ from the pulpy mass, apparently devoid of parts, to its 
proper state of perfection. Hence the strong tendency to severe 
cerebral disease, and the frequency of effusion and convulsive 
affections. 

The imperfect organization of the brain explains, also, the 
absence of those impressions which are made as the child ad- 
vances in age on the organs of sensation ; while the organic 
sympathy is remarkably active, from the much more perfect 
developement of the nerves of the spinal marrow, which are 
found in the foetus of six months perfectly white and fibrous, 
while the cerebral nerves are still gray and soft. To the per- 
fection, also, of the ganglionic or great sympathetic nerve, 
which is more developed in the early periods of foetal existence 
than any other portion of the nervous system, is the peculiar 
feature of an infant's constitution to be referred — the extreme 
susceptibility and extensive and rapid sympathy by which ab- 
normal action is so suddenly transferred from one part to 
another. Although this nerve decreases in size, yet at birth it 
presents nearly the same proportions which exist afterwards. 

The ganglionic system of nerves is the great agent which 
controls and regulates the processes of nutrition and circulation ; 
for foetuses have been found destitute of a cerebrum, cerebel- 
lum, and medulla spinalis ; and where the investigation has taken 
place, the ganglionic system has been seen perfectly developed. 
After undergoing in the uterus the proper developement of the 
vegetative life, such foetuses have died from inability to respire, 
the nerves of respiration arising from the cerebro-spinal centre. 
The superabundance and greater activity of the nerves of 
vegetative life, those on which the growth of the body mate- 
rially depends, are therefore the great sources of the remarkable 
nervous sensibility, so acute and so rapid as it appears in infancy, 
uncontrolled, as it were, by the exercise of those which apper- 
tain to the animal life, and also by the great antagonist of all the 
nervous system, the muscular apparatus. 

From the gradual transition of the brain to its perfect state, 
it might be anticipated that, as the infant increases in age, the 
senses manifest the impression made on them, in proportion to 
the developement of the brain and the nerves conveying the 
impression. 

It is not long before the infant shows its partialities or dis- 
likes — the first manifestation being in the organs of vision. 
Bright objects attract the attention of the infant at a very early 
age ; and it will soon be remarked that it fixes its eyes on any 
brilliantly illuminated object, as a bright light of a window, or 

62 



490 DISEASES OF CHILDREN. 

the glare of a lamp. To gratify this desire infants will often 
subject themselves to inconvenient postures ; hence the impor- 
tance of preventing a glare of light from falling obliquely on 
the child, as the eyes and neck will be distorted by its efforts to 
turn towards the light. 

Hearing would appear to be much less exercised than seeing, 
for the loudest noises do not disturb a young infant even at the 
period when sight is so much enjoyed. The whole of the au- 
ditory apparatus is in a very imperfect state. 

The sense of taste evidently exists, but not to any great ex- 
tent, as it often appears to be a matter of perfect indifference 
what the infant swallows, and a nauseous substance may fre- 
quently be given without its manifesting the presence of any 
unpleasant sensation. That of smell is much less formed. 

The sense of touch, whereby we perceive some of the 
qualities of bodies, scarcely exists in infants, and is slowly 
developed, some degree of experience being necessary to 
perfect this sense. 

The last that are developed, following the organization of 
the brain, are the perceptive and reflective faculties. 

SIGNS OF DISEASE FROM THE NERVOUS SYSTEM. 

Delirium is very common in children on the occurrence 
of the slighest fevers ; and on this account does not afford so 
unfavourable a prognosis as in older persons. Their delirium 
in ordinary febrile excitement is slight, and they can easily be 
roused to a consciousness of their situation. When, however, 
severe inflammation of the brain exists, the delirium is more 
continued, and is proportioned to the degree of inflammation. 
It is often present from the irritation caused by worms, and in 
general is not unfavourable ; but continued sympathetic excite- 
ment of this organ may eventually terminate, in the highly 
susceptible state of an infant, in hypercemia of the brain, or its 
membranes. 

Vertigo, or dizziness, is an unfavourable sign in young chil- 
dren, and during the existence of eruptive epidemics indicates 
a serious invasion of the disease. 

Children are at times morbidly sensitive to all external im- 
pressions, even to slight noises ; this, at the commencement of 
disease, indicates irritation at the central part of the nervous 
system. During apparent convalescence, also, it gives an un- 
favourable prognosis, and is often followed by sudden cerebral 
effusion. 

An infant sleeps the most of its time. Natural, quiet sleep, 
a favourable sign under all circumstances. Sleeplessness, there- 
fore, when it occurs after convulsions, or any sudden affection, 



NERVOUS SYSTEM. 491 

after the violent symptoms have been relieved, indicates a 
morbid irritability of the brain. The absence of sleep, or 
short sleep at the commencement of acute diseases, is not un- 
favourable, and almost invariably exists on the invasion of such 
diseases. 

Excessive sleep in children who have passed the period of 
first infancy, denotes in general softening, effusion, or concussion. 
When the child is teething, it often indicates cerebral pressure, 
from an excessive flow of blood to the head. The various 
states of deep sleep, denominated sopor, coma, and carus, 
always denote some cerebral affection, either congestion or 
inflammation, and are unfavourable when occurring after any 
acute disease, or the exanthemata. Uneasy sleeping and toss- 
ing about in bed are very common in children, and not of them- 
selves to be regarded as of any importance ; but movements of a 
convulsive character usually precede acute disease, or are the 
sign of worms in the intestines. Sudden awaking, where the 
patient cannot immediately recollect himself, often occurs in 
children suffering from the irritation of worms. Dreams of a 
frightful nature indicate a morbid activity in the brain, and, 
at the commencement of acute diseases, mark the probable 
severity of the affection. Grinding of the teeth usually attends 
the presence of worms in the bowels. 

The common sensation, it is obvious, does not in children 
give so^good a diagnostic sign as in adults, from the difficulty 
of ascertaining its existence. It does not, however, differ from 
a similar exhibition in adults. 

The feeling of cold or heat does not exist in proportion to the 
sensation conveyed on touching the skin. In some severe 
cases of fever the feeling of the skin will be cold, while the 
child will not allow of its being covered, apparently from the 
feeling of extreme heat : the arms and legs are immediately 
thrown outside the bed clothes whenever they are covered. 
The alternation from shivering to heat in children, is one of the 
signs of spinal inflammation ; such a disease may be supposed to 
exist when this alternate heat and cold perseveres for a long 
time. At the commencement of disease it is a symptom of but 
little moment. Great heat usually precedes exanthematous 
fevers. 

Pain in general, as in the adult, indicates an affection of the 
organ affected, and may be of simple irritation or inflammation, 
the latter generally ascertained on pressure. This is one of the 
difficult things to diagnose in young children. Pain is, in all 
probability, very severe in them, depending, as it greatly does, 
on the state of the nervous system, which is in a high state of 
susceptibility, and consequently morbidly acute to all impres- 



492 DISEASES OF CHILDREN. 

sions. Severe pain in the orbital region, which may be ascer- 
tained when children are old enough to describe their sensa- 
tions, generally precedes hydrocephalus, if long continued. So, 
likewise, any long continued pain in the head may lead to the 
suspicion of the existence of severe inflammation preceding 
fatal effusion. Heaviness of the head should in no case be dis- 
regarded in young infants, as it is a precursor of the same dis- 
ease. Violent, sudden, lacerating pain, marked by loud and 
sudden screaming, with the application of the hands to the head, 
denotes the existence of deep-seated inflammation of the brain, 
and usually precedes the effusion of serosity. 

With respect to the expression about the face, the eye af- 
fords some important diagnostic signs. The departures from 
the ordinary expression of this organ, are for the most part in- 
dications of cerebral disturbance. 

The pupil of the eye is naturally much larger in infants than 
in older children or in adults. This should always be kept in 
mind when examining the condition of a young infant ; and 
even a more than usually dilated pupil is not always a sign of 
cerebral effusion, for any pressure on the brain, as that arising 
from a too great fulness of the blood-vessels, will produce a 
dilatation of the pupil. An enlarged pupil also indicates a sym- 
pathetic affection of the brain, from irritation in the stomach 
and bowels, often caused by worms. Idiopathic cerebral affec- 
tion may be known by the permanent dilatation of the pupil ; 
and it usually marks the presence of fluid in the ventricles, a 
condition which may reasonably be supposed to exist when 
following cerebral inflammation. This also gives an unfavour- 
able prognosis when it occurs during the progress of hooping- 
cough. After convulsions, also, especially when the child is in 
a soporose state, and lies with its eyes partly open, the enlarge- 
ment of the pupil indicates cerebral effusion. 

A contracted pupil is a common condition during the sleep 
of an infant, and yields no diagnosis ; but the contraction with 
the eyes partially closed when awake, and a knitting of the eye- 
brows, mark the first stage of acute hydrocephalus, or inflam- 
mation of the cerebral meninges. An irregular movement of 
the ball of the eye denotes, also, inflammation of the brain, but 
of less extent than the permanently contracted pupil. 

Strabismus, when occurring after the usual marks of inflam- 
mation of the brain, is an unfavourable sign, especially if it 
make its appearance suddenly. When gradual, it marks some 
slight abdominal affection, or the influence of the exposure of 
the eye to oblique rays of light. Congenital strabismus either 
occurs in chronic congenital hydrocephalus, or denotes the 
natural contraction of one of the muscles of the eyeball. 



NERVOUS SYSTEM. 493 

When the eyes are fixed and staring, or when there exists 
any unusual expression in them, some cerebral disturbance 
exists, and, convulsions may be anticipated. A child will not 
unfrequently start from sleep, and, apparently unconscious of 
surrounding objects, stare wildly, and then lie down quietly ; 
this symptom is usually an indication of some intestinal irritation. 

The expression of the face, arising from the movements of 
the facial muscles, affords a good means of diagonising the dis- 
eases of children, and aiding the practitioner to detect the 
existence of local affections, where the ordinary means of as- 
certaining the presence of local pain are absent, as is the case in 
infants. An alternate expansion and contraction of the nostrils 
attend affections of the pulmonary system. The tumefaction 
of the nose and lips usually indicates worms. 

When the mouth appears to be enlarged, and the lips are 
closely applied to the teeth, while the chin is projecting, serious 
inflammation of the small intestines and stomach exists. A 
continued lateral movement of the lower jaw, like the action of 
chewing, is an unfavourable symptom. 

M. Jadelot was the first to reduce the movements of the face 
to a systematic order, whereby they were made instrumental 
to the more perfect ^diagnosis, the location of their affections 
in one or other of the great splanchnic cavities.* 

The first trait, he remarks, commences at the angle of the 
eye, and loses itself in the projection of the cheek, and is de- 
nominated the oculo-zigomatic trait. This trait or lineament in- 
dicates the seat of disease as being in the cerebro-nervous sys- 
tem. When cerebral disease supervenes on other affections, 
this lineament appears, as in hooping-cough, or affections of the 
primse vise. It may therefore often be seen to precede convul- 
sions or hydrocephalus, occurring after intestinal affections. 

The second appears at the wing of the nose, and passes in 
a semi-circle, more or less complete, around the external edge 
of the orbicularis oris muscle; it is that which is seen in affec- 
tions of the primse viae. The nasal lineament, as this is denomi- 
nated, more particularly points out inflammation in the large 
intestines, or dysentery. 

The third trait or lineament is the labial. It rises at the 
angle of the lips, and loses itself in the lower part of the face 
or chin. It points out diseases of the heart, large vessels and 
air-passages. 

These expressions of the face, in connection with other semeio- 
logical marks, will enable the physician to diagnose the diseases 
of infancy with sufficient accuracy for all practical purposes. 

* Traite des Malad. des Enfans, par M. Underwood, etc., traduit par M. Eusebe 
de Salle. Discours Preliminaire, p. 45. ; Paris, 1823. 



494 DISEASES OF CHILDREN. 

DISEASES OF THE NERVOUS SYSTEM. 
CONVULSIONS. 

The nervous system in infants is naturally in a very susceptible 
condition ; it is consequently easily excited on the application 
of the slightest impressions. This constitutional irritability is 
characteristic of the infant state ; and while it shows itself in the 
sudden invasion of diseases, and their remarkable transmission 
from one organ to the other, it also exhibits itself in the deranged 
action of the nervous system, and the consequent irregular and 
violent action of the muscles. The frequency of convulsions in 
children has long been noticed by physicians, and their great 
fatality renders it of the utmost importance that their causes 
and treatment may be well understood. 

Etiology. — The predisposing causes of convulsions may 
be different, but they are all connected with the great irri- 
tability in the nervous system at the early period of life. 
This nervous sensibility is in excess at this age ; and what- 
ever be the disease with which the infant is affected, a 
morbid excitability and irregularity of action in the nervous sys- 
tem are more or less its attendant ; and the muscles, the irritability 
of which is excited by the natural stimulant of nervous power, 
will, in by far the greatest number of acute diseases, exhibit an 
irregularity of involuntary motion, from a transient movement 
of the eyelids, fingers and toes, to a general convulsion of the 
whole muscular system. 

This excessive sensibility of the nervous system is often 
hereditary, and, like other affections that have been known to 
descend to the offspring, will affect the children of those who 
have themselves exhibited a like tendency to convulsive disor- 
ders. It has been remarked, that the children of parents who 
are very young, or much advanced in years, have a strong dis- 
position to convulsive diseases ; so likewise are the children of 
dyspeptics, inebriates, or such as suffer much from anxiety and 
great depression of spirits. The climate, also, has a great ten- 
dency to impart a predisposition to these affections ; and chil- 
dren in hot countries are much more liable to them than those 
of northern regions ; a greater sensibility being observed in 
all the inhabitants of the torrid zone. 

The natural state of increased vascular action in the brain, 
and the consequent excess of vitality, during its transition from 
the soft mass to its regular organization, also imparts a strong 
predisposition to irregular nervous action, when an excess of ac- 
tion occurs, or any circumstance arises to interrupt the regu- 
lar process of gradual developement. 

Convulsions are either idiopathic or symptomatic ; the for- 



NERVOUS SYSTEM. 495 

mer are not so common as the latter, and usually arise from 
cerebral or spinal meningitis. Whatever be the form convul- 
sions assume, whether spasms, cramps or twitching, it was the 
opinion of M. Brachet that they all arose from an inflamma- 
tion of the meninges.* Symptomatic convulsions are the 
most common form met with among children, and on this ac- 
count they are rather to be regarded as symptoms of other 
diseases than as a disease ; even in that form, dependent on 
the brain itself, they would appear to be but evidences of the 
pre-existence of other affections in that organ. 

Almost every affection of childhood may become a cause 
of convulsion. Irritation in the primae vise, from whatever 
cause, is probably the most common. The retention of the me- 
conium, undigested food, acidity, flatulence, worms, constipa- 
tion, all are frequent causes of this serious affection of infancy* 

The milk of the nurse, also, who indulges in spirituous pota- 
tions, or who is affected with violent fits of passion, or who is 
herself troubled with disease, especially of the digestive organs, 
will often produce convulsions in children that are nursing. 
Numerous instances have occurred of sudden convulsions from 
a violent fit of anger. Loud noises, or sudden terror, will also 
cause convulsions ; and in children that are old enough, the 
sight of others affected with them, or with other alarming dis- 
eases, will also produce them. So will any other cause that 
violently affects the nervous system, especially if it be sudden. 

Violent blows on the head, or a concussion of the brain from 
falls, more especially from the landing on the feet when the 
limbs are kept extended, as is very common for children when 
jumping from a chair or any other height when in play, will 
produce severe concussion, and often convulsions of the most 
dangerous character. Some organic lesion, tumours, deposits 
of bony matter, and effusions, are also very common causes of 
convulsions. 

Convulsions are very common during the period of teething ; 
the febrile action, with the increased flow of blood to the brain 
at this period, when the latter is in the active state, arising from 
the process of the organic changes, become an exciting cause 
of convulsive diseases. 

The various exanthematous diseases, also, especially during 
their invasion, often bring on convulsions, particularly w T hen, 
from the interruption of the natural order of their progress, an 
imperfect developement occurs. The sudden suppression, also, 
of these disorders, will produce convulsions at any period du- 
ring their course. 

* Brachet, Mem. sur les Causes des Convulsions, etc. ; Paris, 1824. 



496 DISEASES OP CHILDREN. 

A most common cause is the drying up of cutaneous dis- 
charges. Such as those occurring behind the ears, tinea, crusta 
lactea, etc., are frequently followed by convulsions, unless a 
free discharge from the bowels, either occurring spontaneously, 
or produced artificially, comes to the relief of the oppressed 
system. 

Whatever causes an inordinate flow of blood to the head, 
may endanger the life of the child by the production of con- 
vulsions. Violent paroxysms, therefore, of hooping-cough, by 
crowding the brain, will at times cause them, and the exces- 
sive use of opiates in the same way will become an exciting 
cause of convulsions. Debility, and the absence of the natural 
stimulus to the brain, will also produce them. 

Another cause is the action of emetics or drastic cathartics 
in some children. Protracted cases, also, have been caused by 
the persevering use of tartar emetic, as a nauseant. In sucking 
children, also, preparations of lead, which have been used for 
the purpose of washing inflamed nipples, have excited them. 
In short, any derangement of the system, from almost any source, 
will produce convulsive action in the muscles of infants and 
young children. 

Semeiology. — It is not usual for convulsions to occur sud- 
denly, without any previous indication of such a tendency in 
the child. Among other precursors is restlessness during sleep, 
with occasional waking in terror. When awake, the eyes 
appear restless, and their expression is usually more brilliant 
than ordinary, and it is not an uncommon thing to see the child 
immediately before the paroxysm, especially if awaking from 
sleep, stare wildly about the apartment. Mr. North, who has 
written an excellent work on this subject, has described with 
great accuracy the premonitions of this affection. He speaks 
particularly of the fixed staring of the eyes, and the alternate con- 
traction and dilatation of the pupils, a symptom of very com- 
mon occurrence. A highly flushed face is also a very usual 
appearance preceding an attack of convulsions, and this may 
be looked for when it becomes suddenly red, accompanied by 
the expression of the eyes above mentioned. At times, a child 
will appear more than usually animated for a short period, but 
-quickly relapses into a quiet and languid condition. Some chil- 
dren that are of a debilitated habit do not always exhibit a red 
or turgid condition of the face, but the countenance, on the 
contrary, is pinched, with some degree of lividity, especially 
about the mouth. 

When convulsions occur, they may be either partial or gene- 
ral, affecting only a few of the muscles, especially about the 
face, or exhibiting the irregular action of the whole muscular 
system. 



NERVOUS SYSTEM. 497 

The action of the orbicular muscle of the mouth, and of 
some of the muscles moving the jaw, is not an uncommon 
occurrence, without the convulsive movement of any others. 
This appears to be connected with the presence of undigested 
food in the stomach, as I have seen it promptly removed on 
the occurrence of free vomiting. 

It is most common, however, for all the voluntary and some 
of the involuntary muscles to be affected. At times the con- 
traction and relaxation occur only on one side ; and again 
they will alternate with the opposite, in regular succession. 
After a paroxysm, the child cries, and then falls into a profound 
sleep. The paroxysms are very liable to be renewed until 
the cause is removed. 

Other diseases affecting the proper movements of the muscles, 
and arising from the same causes, are very common in infants ; 
such as clonic spasms, including the carpo-pedal spasm and 
tetanus. The former often occurs during the period of teething; 
the latter, at an earlier period of life, and generally prevails within 
the tropics.. Cullen, however, mentions that it has been seen 
in the Highlands of Scotland, but never in the Low Countries. 

Carpo-pedal spasm, as its name indicates, is characterized 
by a spasmodic affection of the flexor muscles of the hands and 
feet. The thumb is rigidly contracted into the flat of the hand, 
and the wrist, also, is drawn inward ; the toes, from the same 
cause, are drawn downward, and bent under the foot. A 
spasmodic affection at the same time occurs in the larynx and 
chest, whereby a crowing or croupy sound is imparted to the 
respiration ; it is evidently therefore connected with a similar 
morbid state of the nerves, which produces some cases of the 
spasmodic variety of croup. This form of the disease was 
first described by Dr. Clark, of Dublin.* Several interesting 
accounts of the disease have been given by Dr. Kellie and Dr. 
North.f Dr. Johnson has also published some valuable re- 
marks on this subject.J As this form of convulsive affection 
depends on the causes already detailed, it is unnecessary to 
give them more at length ; the reader may therefore consult 
these essays for a minute description of the disease. 

The prognosis is generally uncertain while the paroxysm 
continues ; for although the cause may be apparent, and per- 
haps easily removed, yet it is not in our power to ascertain 
the precise extent of the pathological condition of the brain 
and spinal marrow. When quickly removed, we may gene- 



* Commentaries on the Diseases of Children; Dublin, 1315. 
t On the Convulsions of Infants; Lond., 1826. 
t Med. Chir. Review, vol. iii. 1817. 
63 



498 DISEASES OF CHILDREN. 

rally consider it as favourable. When arising from any injury, 
convulsions are justly regarded as indicating great danger. 

Morbid Anatomy and Pathology. — Dissections exhibit a 
great difference in the appearance of the brain and spinal mar- 
row, depending on the exciting cause of the disease. In some 
instances there have been discovered tubercles and other organic 
changes; while in others a simple vascular turgescence, with a 
greater or less degree of effusion in the ventricles. Inflamma- 
tion of the membrane of the brain and spinal meninges is also 
frequently found in children that have died from convulsions. 
M. Billard.* from a number of autopsical examinations, is of 
opinion, that the convulsions of children arise, in the greatest 
number of instances, from inflammation of the spinal meninges, 
particularly in the part near the base of the brain. He thinks, 
also, that an irritation in the seat of the affection may manifest 
itself before inflammation is produced, which it would be diffi- 
cult or impossible to detect on dissection. If this irritation pro- 
duce convulsions which are quickly fatal, it is evident that no 
organic change would be found. 

This condition sometimes exists; and the nervous centre has 
also been in a state the very opposite of vascular congestion or 
inflammation. Convulsions may therefore arise from the irrita- 
tion produced by the loaded and inflamed condition of the brain 
and spinal marrow, and likewise from the want of this natural 
stimulant. Excessive hemorrhage will not unfrequently pro- 
duce convulsions ; and bleeding, as a remedial measure, when 
carried to the extreme, is often followed by convulsions in young 
children. Whatever, therefore, disturbs the action of the ner- 
vous energy will produce convulsive action, whether this arise 
from an excessive stimulation of the part, or a diminished action 
from congestion or exhaustion. 

As is evident from the numerous causes of this affection, con- 
vulsions are not always produced by a primary irritation of the 
brain or spinal marrow, and the morbid cause disturbing the 
regular nervous action often exists in a distant part, more par- 
ticularly in the stomach and intestines ; the irritation is there- 
fore transmitted through the great sympathetic and its ramifi- 
cations. From this fact we see the cause of the frequent occur- 
rence of convulsions among children, where the ingesta are gen- 
rally greater than the requirements of the body. From the 
extreme irritability, also, of the nerves, any irritating cause 
existing in the bowels, whether it be the meconium, worms, or 
hard, undigestible substances, will become a cause of this affec- 
tion. I once had a case of a child about four years of age, 

* Op. Cit, p. 477. 



NERVOUS SYSTEM. 499 

who obtained no relief from the most severe convulsions, until 
a copious discharge was obtained from the bowels, when a large 
number of cherry- pits were evacuated. Constipation, also, has 
terminated in convulsions, and ultimately in death.* That it is 
not necessarily connected with the brain is evident from the 
fact, that some children, when suffering from severe convulsions, 
will remain in possession of all their perceptive faculties. In- 
stances of this I have occasionally seen, and they generally 
occur when the convulsive movements are partial. In one in- 
stance, however, which lately came under my observation, in a 
child of ten years, the affection of the muscular system appeared 
to be universal, and lasted for six hours with great severity ; the 
eyes were fixed obliquely. On his recovery he spoke of the 
perfect possession of his mental powers, and described the mea- 
sures which had been adopted for his relief, although unable to 
articulate during the paroxysm. Although involved in great 
obscurity, yet it is evident that most cases of convulsions in 
children are connected with the ganglionic nerves of the great 
sympathetic, from irritation in the bowels. 

Treatment. — For the proper management of convulsions, it 
is obvious that the cause should at first be ascertained and re- 
•moved. It is therefore of the greatest importance that correct 
information be obtained, if possible, as to the general condition 
of the child, and the circumstances connected with the invasion. 
Sometimes it will occur immediately after eating, and depends 
on the food irritating the stomach, which ought to be imme- 
diately removed by an emetic, if it be possible to administer one. 
In the majority of instances the child is unable to swallow; and 
any attempt to give medicine by the mouth only aggravates the 
disease, by the obstruction it produces in the respiration, and the 
strangulation it causes. Where it is evident that indigestible 
food has been recently eaten, and an intermission occurs suffi- 
cient to give the medicine, a gentle emetic of ipecacuanha ought 
to be given as the least irritating, the object being simply the 
evacuation of the stomach. The syrup of ipecacuanha for 
young infants, or tartar emetic combined with powdered ipeca- 
cuanha for older children, will be sufficient to accomplish this 
object. 

During the paroxysm it is often impossible to give an emetic; 
under such circumstances, and whenever there is any reason 
for believing the existence of irritating matter in the bowels, a 
common enema should be given. An enema not only evacuates 
the bowels of accumulated feces, but has a quieting effect in 
cases of convulsions, probably from its revulsive effects. In 

* Morgagni, Epist. 31. 



\ 



500 DISEASES OF CHILDREN". 

infants it may consist of a small quantity of olive or castor oil, 
with warm water. In older children, especially when the con- 
vulsions are attended with turgescence of the head, it may be 
made more stimulating, either by using a solution of common 
salt, or an infusion of senna. In very young infants it is 
often caused by the extrication of gas in the bowels ; this may 
be suspected when the child has cried much, and given the usual 
evidences of colic pain. In addition to an enema, the abdomen 
may be gently rubbed with a little warm brandy or liniment on 
the hand, and as soon as the state of the child will admit, a suit- 
able dose of castor oil must be given. 

It is usually the custom to immerse the child in a warm bath ; 
where, however, there is much plethora, or a loaded state of the 
brain, the universal application of warmth seems to aggravate 
the symptoms. A partial warm bath, by immersing the legs in 
warm water, appears to afford more relief by the revulsion it 
occasions, especially if the head be at the same time covered 
with cloths dipped in cold water. Under all circumstances 
the gums should be examined, and if evidences exist of the 
pressure of the teeth on the gums, they ought to be liberated 
by making a free incision. 

In children of a full, robust habit, if the paroxysms be not- 
quickly relieved by the measures above mentioned, it will be 
necessary to draw blood from a vein in the arm. In such 
habits it often happens that other measures will have but a 
very imperfect effect until a little blood is drawn ; a cathartic 
or an emetic having scarcely any operation until the pressure on 
the brain is removed. This may often be accomplished in in- 
fants by the application of a few leeches behind the ears. 

It was remarked that convulsions may arise from two oppo- 
site conditions of system ; it would therefore be obviously im- 
proper to resort to bleeding in every case, even when they are 
protracted for a long time after the app-arent cause is removed. 
When any doubt exists as to the state of the system, the condi- 
tion of the fontanelle will point out the state of the brain. 
When the former is convex, there can be no question as to the 
plethoric or congestive condition of the brain. The depressed 
or hollow state of this opening, on the contrary, indicates a de- 
ficiency of fluids, and requires an opposite course of treatment, 
or rather the avoidance of a direct sanguinary depletion. 
This state is connected with other evidences of debility, and 
want of the proper and healthy quantity of fluids, as appears 
from the pale and wasted condition of the body, first pointed 
out, I believe, by Dr. Locock. Whatever be the temporary 
condition of the face, having the marks of vascular turges- 
cence during the immediate paroxysm, if a permanent con- 



NERVOUS SYSTEM. 



501 



cavity exists in the fontanelle, bleeding must not be resorted to 
for the removal of the convulsions. 

In this condition of system, and also, after the necessary de- 
pletion in that arising from increased vascular action or tumes- 
cence, when the convulsions are kept up by a morbid irritabi- 
lity engendered in the system, it will be necessary to resort to 
such measures as will calm the disturbance of the nervous sys- 
tem. Antispasmodics, however, ought never to be used until 
the supposed causes on which the convulsions depend are re- 
moved. After the bowels have been relieved, and such other 
means adopted as the case requires, to remove every probable 
cause of the disease, antispasmodics and composing medicines 
may be very properly adopted. 

Among the best articles of this class, is assafoetida, which 
may very properly be given in an enema, especially in such 
cases as depend on intestinal irritation as the primary cause. 
From six to eight grains may be blended with an infusion of 
flaxseed for a young infant, or a scruple to half a drachm for a 
child two or three years old, to be repeated according to the 
necessity of the case. 

Musk is another very powerful agent in controlling the mor- 
bid irritability of the nervous system, when it is connected with 
debility ; it appears also to be particularly beneficial when con- 
vulsions depend on the sympathetic irritation of the ganglionic 
nerves. Its benefits are obvious, in proportion to the ab- 
sence of sanguineous fulness. It may be given in the dose of 
half a grain to two grains every hour to young infants, or when 
there is much prostration, in the subjoined forms.* 

Those medicines, also, which act from their narcotic powers, 
are also useful in allaying the excessive nervous irritability. 
Opium, however, is objectionable, from its effects in arresting 
the secretions. Hyoscyamus possesses properties analogous 
to opium, and from its tendency to promote the intestinal se- 
cretions, and to allay morbid irritation after its immediate 
narcotic influence has ceased, is well adapted for children. It 
may be given in the dose of a quarter of a grain to sucking 
children, and from two to five grains to children from four to 
seven years of age. When there exists any febrile heat, it may 
be given with ipecacuanha or James's powder. If, on the con- 



* fy Moschi, qr. vi. 

Amon, Sub. Carb., gr. iv. 

Sacchar. Albi, 3iij. 

Aquae, §iss. M. 
A teaspoonful every hour, to an in- 
fant. 



Ifr Moschi, gr. iij. 
Tere cum 

Aquae Anisi., 3vi. Adde 
Spts. Amon. Foetid., 3j. 
Syrup. Simpl., gj. M. 
A teaspoonful every hour, to an infant 
of 6ix months. 



502 DISEASES OP CHILDREN. 

trary, the most prominent symptoms be those of debility, 
hyoscyamus may be used with some stimulant, as valerian.* 
It has also been used in infantile convulsions, combined with 
calomel, in obstinate cases, where it evidently depends on the 
primary irritation of the gastric mucous membrane. It has 
been used in France, in the dose of a grain and a half every 
half hour, with two grains of calomel every two hours, to a 
child two years of age. 

In cases of frequently recurring convulsions, attended with 
great debility and emaciation, it will become necessary to have 
recourse to some direct tonic, as the carbonate of iron, in the 
dose of five grains to a scruple, to a child five or six years of 
age. The phosphate is also a useful preparation, and may be 
given in similar doses. 

Stimulating applications to the spine are often of great effi- 
cacy in protracted cases of convulsions. Benefit is often 
derived, also, from the employment of such as possess some 
direct antispasmodic properties, as the oil of amber, applied 
with a piece of flannel to the whole course of the spine. 

Convulsions in children being so often connected with a 
deranged state of the prima? via?, a close attention to the state 
of the stomach and bowels is necessary, where the child is 
predisposed to these affections ; in preventing a costive con- 
dition, by the occasional use of laxative medicine and enemata; 
in regulating the secretion, by the judicious use of blue pill and 
ipecacuanha, where the whiteness of the stools indicates a 
deficiency in the biliary secretion ; but more especially in the 
supply of suitable nourishment, according to the age of the 
child. A change of diet, about the age of two years, "will often 
effect more than medicine, where the child has been too exclu- 
sively fed on pap. Chicken broth, and animal food generally, 
should be adopted, where convulsions persist under such 
circumstances ; a marked alteration will appear in the health 
of the child. 

CHOREA. 

A disease exhibiting every symptom of chorea was described 
by the ancients with great accuracy, at least so far as the lower 
extremities were concerned; from the irregular motions of 
which it took its name. In later times it has received the name 
now usually adopted, which is derived from the Greek, and 

* fy Ext. Hyoscyam., gr. v. 

Tinct. Valerianae, C. gtt. xx. 
Syrup. Simplicis., gss. 
Aquae Cinnamon., §ss. M. 
A teaspoonful may be given every hour, to a child from six months to a year. 



NERVOUS SYSTEM. 503 

signifies a company of dancers. It was in Germany that the 
appellation of St.Vitus's dance was first applied to this affection, 
from the tradition that this saint was a sufferer from the disease. 
A chapel was dedicated at Ulm, in Souabia, where such as 
were afflicted with this disorder repaired, and offered their vows 
and prayers for relief. The name of St. Vitus has therefore 
been added to the other appellation, and it has by some nosolo- 
gists been distinguished by the title of Chorea Sancti Viti. 

Etiology. — The predisposition is found in the age of the 
patient, and it chiefly occurs between the ages of eight and 
fourteen, especially in those who are debilitated from sedentary 
habits. Whatever produces a morbid irritability of the nervous 
system predisposes to this disease. The greater susceptibility 
of the nervous system in females renders them much more lia- 
ble to this affection than males. Of an aggregate of one hun- 
dred and seventy-four cases, reported in various medical jour- 
nals, one hundred and twenty-two were girls and fifty-two boys. 
Dr. Elliotson states, as the result of his experience, that the 
proportion is as three to one. 

Among the occasional causes is found terror or fright ; seve- 
ral cases are reported as arising from these causes. Imitation, 
also, has produced chorea. Wounds and injuries on the head 
have likewise been followed by this affection. The various dis- 
orders of children have at times preceded chorea ; among these 
are teething and suppressed eruption. The retarded appear- 
ance of the catamenia is also a very common cause. The 
most common, however, is gastric or intestinal irritation from 
worms, or disordered secretion or constipation ; all which are 
of very common occurrence before puberty. 

Semeiology. — The first symptom shows itself in the inability 
to control the motions of the arms or legs ; usually the limbs of 
one side exhibit the convulsive movements which mark the dis- 
ease The child is observed to halt or stumble in walking, or 
to twist the foot of the affected limb awkwardly on attempting 
to place it to the ground. When it appears in the hand or arm, 
the same awkward motions are noticed, together with a total 
inability to retain the member in the situation in which it is 
placed. These are particularly observed to occur when the 
child's motions are watched, when they often become quite lu- 
dicrous. The hand is more than usually unsteady, whenever 
the child wishes to preserve its proper motions ; as in carrying 
a glass of water to the mouth. All these involuntary motions 
increase until, in the most aggravated forms, all the actions are 
performed by jerks ; the walking by a species of jumps or starts, 
while those of the arms are equally unsteady. At times the 
limbs have the appearance of being paralyzed, especially the 
lower extremities. 



504 DISEASES OP CHILDREN. 

In very severe cases it appears to affect all the voluntary 
muscles ; and the distortion of the face and protrusion of the 
tongue impart a ludicrous and sometimes a distressing appear- 
ance to the countenance. 

Morbid Anatomy and Pathology. — Effusion has been found 
in the ventricles of the brain, with the appearance of tumes- 
cence or chronic inflammation;* in other instances tumours 
have been seen in the cerebrum. Dr. Hawkins discovered no 
lesion in the brain in a fatal case examined by him, but the source 
of irritation appeared in some of the abdominal and thoracic 
viscera, f M. Serres also mentions cases where no morbid con- 
dition could be found in the brain. J 

Dr. Coxe is of opinion that it arises from hydrocephalus, or 
the inflammation which precedes this disease. It appears to 
be often connected with it either as a cause or effect ; but it 
is difficult to ascertain from dissection which is the primary 
affection. It is not necessary that lesions should always at first 
exist in any part of the cerebro-spinal system to produce this 
affection ; for, like other diseases of a similar nature, it may 
have its cause in some remote organ, and, when once excited, it 
may often be kept up by habit, even after the cause is removed. 
A morbid susceptibility, it is obvious, often exists in the nervous 
system, whereby an emotion of the mind will be productive of 
irregular muscular action ; it can hardly be supposed that under 
such circumstances there can exist any appreciable vascular 
turgescence. 

Treatment. — As the disease is so varied in its cause, the treat- 
ment consequently must have strict reference to its origin, if this 
can be discovered. One of the most frequent is the deranged 
condition of the primse viae ; it must receive the first attention. 
The use of purgatives formed the principal method of treatment 
with Sydenham, and was revived by Dr. Hamilton. It is by no 
means necessary to resort to powerful and active purging, even 
where the furred tongue, offensive breath, and other symptoms, 
point out the primary irritation to be in the intestines ; mild 
aperients will be all that is needed to remove the cause of the 
disease in delicate patients, the operation of active purgatives 
often adding to the exciting distress. Details of treatment ap- 
plicable to the removal of the causes of chorea, will be found 
under the various heads of worms, indigestion, hydrocephalus, etc. 

When connected with a disordered condition of the secre- 
tions of the abdominal viscera, it is always found in pale, debi- 



* Dr. Coxe's Med. and Phys. Jour., vols. xiii. and xviii. 
t Lond. Med. and Phys. Journal, vol. xvii. 



NERVOUS SYSTEM. 505 

litated and irritable subjects. It will, therefore, often become 
necessary to have recourse to tonics, where the condition of the 
mucous membrane does not counter-indicate their use. The 
metallic tonics especially have been the most extensively em- 
ployed, and found more successful than those from the vege- 
table kingdom. Among the remedies of this nature, the sub- 
carbonate of iron has been the most successful, in doses of from 
five to twenty grains. It is usual to prescribe it with some 
aromatic* Other preparations of iron have also been used 
in chorea ; the sulphate, in doses of three or four grains, to chil- 
dren eight or ten years old. Zinc, also, in the form of oxyde 
and sulphate, has been prescribed with great advantage in this 
disease ; the former, from two to five grains, and the latter, 
from one to three grains, to children between four and eight 
years. Trie nitrate of silver has been used with benefit in ob- 
stinate cases of chorea, connected with a disordered condition 
of the digestive organs. Arsenic has also been found efficacious 
in adults, where tonics are indicated ; but from the powerful 
impression it makes, and the rapid absorption in children, I am 
inclined to think it a hazardous remedy. 

Iodine has lately been used with great success by Dr. Peltzf 
and others ; the dose and manner of its exhibition will be found 
under the head of scrofulous diseases. 

Narcotics and antispasmodics have also, at times, been at- 
tended with good effect, when the disease has been kept up by 
habit, connected with a morbid sensibility of the nervous sys- 
tem, independent of any local cause. Belladonna, opium, cam- 
phor, valerian, musk, and other medicines of this class, have 
been used for this purpose. 

In long continued cases I have used electricity, but with no 
advantage ; it has, however, in the hands of others, been suc- 
cessful. 

Regular exercise in the open air, cold bathing, constant oc- 
cupation, together with the tonic course above mentioned, and 
a residence in a dry and cool section of country, will, with or- 
dinary precautions in removing the exciting cause of the dis- 
ease, almost certainly effect a cure. 



* ~fy Ferri Sub-carb., gr. x. 
Pulv. Valeriana, gr. xx. 
Syrup. Zingiber., q. s. M. 
ft. bolus. 
For a child often or twelve years, 
t N. A. Med. and Phys. Journal, yoI. ii. 

64 



506 



DISEASES OF CHILDREN. 



HYDROCEPHALUS. 

This disease receives its name from the effusion of serous 
fluid in the ventricles and other cavities of the brain, occurring 
either suddenly or in a very gradual manner, and preceded 
either by a very marked acute inflammation, or by a chronic 
state of irritation in the arachnoid membrane. In the latter 
case it is often congenital, and may continue for a number of 
years; the skull separated at its sutures, being widely distended, 
and exhibiting an enormous increase in its size. It is, therefore, 
properly divided into acute and chronic. 

ACUTE HYDROCEPHALUS. 

This form of the disease has received the various synonyms of 
hydrocephalus internus, hydrencephalus, febris hydrocephalica, 
apoplexia hydrocephalica, eclampsia ab hydrocephalo, arach- 
nitis, meningitis, dropsy of the brain, etc. The term at the 
head of this article appears to be the best, as it includes in its 
signification all the possible varieties, and is not adverse to the 
doctrine of previously existing inflammation ; while other terms, 
as arachnitis, or meningitis, cannot be always applicable to the 
affection now under consideration, for the affections may not 
always terminate in effusion, which is the disease here consi- 
dered. 

It appears not to have been noticed as a distinct disease by 
Hippocrates and other ancient writers, although the father of 
medicine alludes to the existence of water in the brain, in a 
manner that leaves a doubt whether he referred to an external 
or an internal accumulation of water. But both Hippocrates 
and Celsus, as well as other ancient authors, doubtless saw the 
disease, and there is no reason for believing that in their account 
of it, under precisely the same title as it is now described, 
v5poKe<p a \ov, they never mentioned any other disease, although 
a question has been raised on the subject.* 

In the year 1733, Mr. John Paisley published a clear account 
of the disease occurring in a boy aged about six years, who 
was attacked with the usual symptoms of inflammation of the 
brain. The case terminated fatally, and on examining the brain, 
a tumour presented itself, formed of the dura matter, enclosing a 
small quantity of serum. In the ventricles, also, there existed a 
large quantity of yellowish serum. j* 

The first complete essay, however, was published by Dr. 
Whytt, professor of medicine in the University of Edinburgh, 

* Hippoc, De Morb., Lib. ii. sec. v. Celsus, De Med., Lib. iv. Cap.ii. 
t Med. Essays;, Edinburgh, vol. iii. p. 333. 



NERVOUS SYSTEM. 507 

in 1768,* in which a very accurate and philosophical account 
of the disease is given. This essay is replete with excellent 
practical remarks on the different appearances of the disease at 
different periods. The symptoms are accurately described, 
and its division into the very obvious distinction of different 
stages, shows the accuracy of the distinguished author's obser- 
vations. The pathology of the disease is necessarily imperfect, 
and the treatment consequently not so energetic as that adopt- 
ed at the present day. 

The subject has received the attention of Fothergill, in Eng- 
land, Odier, in Switzerland, and our distinguished countryman, 
Dr. Rush. Of late years, Bricheteau, Cheyne, Yeats and Coin- 
det, have published excellent remarks on this subject. One of 
the most complete essays that has ever appeared, is that of Dr. 
Golis, of Vienna, a translation of which has been made into 
English, by Dr. Gooch. Dr. Golis considers the disease, as it 
was regarded by Dr. Quin, Dr. Rush, and others, as an inflam- 
matory affection, and the effusion as the effect of this cephalitis ; 
but, like them, does not extend his views to the most frequent 
origin of the disease in the chylopoetic viscera. 

Etiology. — Authors generally have remarked, that those 
children who have large heads are more predisposed to hydro- 
cephalus than others, and that it occurs more frequently in 
children of great precocity of intellect. This, in itself, can 
scarcely be regarded as a necessary condition of the disease, 
although it not unfrequently has been found to co-exist with it. 
Those children who possess a quick sensibility, and who also 
give evidence of great excitability in the nervous system by 
irregular spasmodic movements, are evidently more predisposed 
to this disease. 

One of the most common predisposing causes of this disease, 
which is one almost exclusively of infancy and childhood, is 
the growing condition of the brain, and the extreme activity 
of the blood-vessels from that cause. The brain, during the 
first periods of life, undergoes great organic modifications, and 
the exercise of its peculiar functions has also been remarkably 
developed; for it gradually acquires a control over the other 
organs, and becomes fitted to receive the impressions from 
them. It is on this account, as M. Billard observes, that 
during the early months of the child's existence there is but little 
excitement in the brain, it then undergoing nothing more than 
organic change ; but as it becomes fitted to receive impressions, 
fever and inflammation ensue, often from very slight sympa- 
thetic irritation, as derangement from indigestible substances, 

* Obs. on Dropsy of the Brain, etc. ; Edinburgh, 17G8. 



508 DISEASES OP CHILDREN. 

dentition, so common in children ; for acute hydrocephalus is 
not a disease of early infancy. The predisposition to cerebral 
disease is also hereditary, and it is not an unusual circumstance 
to see several individuals in the same family affected with the 
disease, as has been remarked by Cheyne, Coindet, Brachet, 
etc. Armstrong mentions the occurrence of the disease in 
four brothers, and Underwood, the death of six, at the age of 
two years. I have known of four deaths occurring in one 
family from this cause, successively arising as the children 
arrived at the age of two or three years. 

Dr. Percival has, by recording a number of cases, deter- 
mined the age with considerable accuracy at which children 
are most disposed to hydrocephalus ; and from his observations 
it appears that it most commonly occurs between the ages of 
two and seven years. M. Coindet, of Geneva, has also, by 
means of tables of deaths kept for twenty years, ascertained 
the same facts. A similar result is also found in the tables of 
Dr. Emerson, of the deaths occurring in Philadelphia for twenty 
years, recorded in the first Volume of the American Journal of 
the Medical Sciences; for, out of 1,602 cases of fatal hydro- 
cephalus, 1,395 occurred before the fifth year, and between 
the ages of five and ten. These facts go to illustrate, in a re- 
markable manner, the influence of the increasing activity and 
sensibility of the brain in predisposing children to acute hydro- 
cephalus. Dr. Green states, that it is between the ages of five 
and seven that the greatest number of cases occur.* 

It is said to prevail more in some countries than others. In 
England, France and the United States, it is a frequent and 
fatal disease, while it is rarely to be seen in Holland and Swit- 
zerland, according to the statements of Camper and Tissot. 

The exciting causes of this disease are very numerous ; in- 
deed, there is scarcely any affection to which children are sub- 
ject but what may become its occasional cause, while blows, or 
any injury or compression of the head, are also the agents of its 
production. The causes then divide themselves into direct and 
indirect, idiopathic and symptomatic. Blows and falls on the 
head are frequent exciting causes, as young children are much 
exposed to them from want of strength in supporting themselves 
while learning to walk ; they often, however, thus experience 
injury, without any serious or lasting consequences resulting. 
The blows, therefore, ought to be sufficiently powerful to pro- 
duce an inflammation of the meninges of the brain, from the 
violence of the concussion. Extreme heat is also another ex- 
citing cause, especially from the rays of the sun, whereby an 

Lancet, vol. ii. 1835. 



NERVOUS SYSTEM. 509 

inordinate flow of blood to the head is produced, terminating in 
inflammation of the arachnoid membrane. 

The indirect causes may arise from various abnormal condi- 
tions of the system, and among these is that of suppressed erup- 
tions, or of habitual discharges, such as that so common to chil- 
dren, the serous and puriform oozings from excoriations behind 
the ears. Among this class of causes are scarlet fever, mea- 
sles, and other eruptive diseases ; the former most frequently, 
when fatal, terminating in hydrocephalus. It has in these cases 
been supposed by many authors to arise from an interruption in 
the regular course of the disease, which has its proper periods 
of incubation, progress and maturity ; this irregularity being 
produced by the impression of the external air, as Bricheteau 
supposes. Whatever be the cause of the metastasis, nothing 
is more common than to see it follow cutaneous affections, and 
those sometimes of a very slight character, as the miliary 
eruption. 

Intestinal irritation, or irritation of any of the digestive vis- 
cera, is also a very frequent cause of the disease in question ; 
and authors ascribe it, in a great number of instances, to the 
sympathy existing between the various abdominal viscera and 
the encephalon. This strong tendency to cerebral inflamma- 
tion, in diarrhoea, cholera infantum, and other diseases of the 
chylopoetic viscera, in infancy and childhood, is familiar to the 
most casual observer; and, indeed, is so frequent a termination 
of these affections, as to cause all diseases of the head to be 
referred by some physicians to the digestive canal as their sole 
origin. Among these more particularly are M. M. Sabrioles* 
and Senn ;f the former of whom has devoted an octavo volume 
of three hundred pages to the consideration of this subject; 
both regarding gastro-enteritis as the principal, and, indeed, the 
sole cause of these affections of the head. There can be no 
question of the strong tendency to diseases of the head in chil- 
dren, where there exists much disturbance of the bowels, and 
especially where there is any inflammatory action ; both these 
affections often appear simultaneously, as is evident from the 
symptoms, which will be noted when that portion of the subject 
comes under consideration. These evidences of gastric and 
intestinal disturbance are important diagnostic signs of the na- 
ture of the exciting cause, and on which a successful treatment 
of the ordinary hydrocephalus very essentially depends ; for 
the removal of any irritation from the bowels, whether it be 
worms, or acrid secretion, often is important in removing the 

* Recherchesd'Anatomie et de Phys. Pathol, etc., par G. Sabrioles; Paris, 1826. 
t Recherches Anatomico-Pathologiques sur la meningitis ; Paris, 1825. 



510 DISEASES OF CHILDREN. 

first link in the chain. These views are not peculiar to the 
French physicians, but were long since entertained by Harris, 
and more recently more closely investigated and practically 
applied to the disease before us, by Drs. Cheyne and Yeats. 
In addition to the deranged condition of the alimentary canal, 
they considered the congested, sub-inflamed or sluggish state 
of the liver, as the principal exciting cause of the common cere- 
bral affections in children — views more in accordance with gene- 
ral experience and the practical benefits derived from them. 
This extended consideration of the subject, in leading the prac- 
titioner to anticipate the disease, when the symptoms of de- 
ranged action in this viscus are apparent, gives a high value to 
these treatises, and makes them important, as marking a new 
era in practice, as relates to this disease. 

The irritable state of the system during dentition is also a 
subject of common observation ; and the excitement attendant 
on this state is an active agent in the production of hydrocepha- 
lus, both from the general febrile condition, as well as the inor- 
dinate determination of blood to the head, from the sympathy 
arising from contiguity of parts. 

Violent paroxysms of coughing, crying, and even of anger, 
become exciting causes of inflammation of the membranes of 
the brain, terminating in effusion, by causing an excessive flow 
of blood to the cerebrum. ' In like manner, an inordinate use 
of the cradle has been found hazardous, from its producing si- 
milar effects, convulsions having, in some instances, been brought 
on by violent rocking. A moderate motion often has a soothing 
effect, and cannot be regarded as hazardous; but the practice of 
continued and violent motion of the cradle, cannot be too highly 
reprobated. As was just remarked, violent coughing is a pro- 
minent cause ; to this, therefore, may be referred the effusions 
in the brain, so commonly following hooping-cough. But in 
addition to this cause, there is doubtless existing in all children 
a predisposition to cerebral disease : the simple excitement 
attendant on protracted hooping-cough is sufficient, in some 
instances, to cause the developement of arachnitis. 

All these facts unquestionably prove the predisposition to 
exist in the brain of children, from some peculiarity at this pe- 
riod of life, which exposes it to be excited by derangements 
existing in other parts of the system, by which it participates 
in common with others. But from excessive circulation in the 
brain, evident in the great size of the head of children in pro- 
portion to other organs, and its excitable condition, as appears 
from the extreme mobility of the nervous system, there can 
scarcely remain a doubt that this condition of developement is 
what predisposes it to be so easily affected by derangements in 



NERVOUS SYSTEM. 511 

the system generally, which excite preternatural action in the 
blood-vessels. Physiologists generally, from Stahl to Bichat, 
have noted particularly the condition of the cerebral organ, and 
have considered it as the predominant organ of the period of 
childhood ; by which is probably meant the organ which, from 
its imperfect developement, needs a large supply of blood to 
carry on the process which nature requires, and, therefore, cir- 
culation predominates in this viscus ; for it can scarcely be re- 
garded as a predominating organ, when its essential function 
of thought is but in imperfect action. 

Semeiology. — The invasion of hydrocephalus is often like 
that of an ordinary fever arising from derangements of the ab- 
dominal viscera, and is marked by similar symptoms, such as 
colic pains, nausea, vomiting, and sometimes, as the disease ad- 
vances, is accompanied by a diarrhoea of green discharges, 
showing an excess of biliary secretion. The sleep is disturbed, 
the child also waking as if alarmed. These symptoms may 
continue for several days, or even weeks, as was long since no- 
ticed by Dr. Whytt. At other times the invasion is sudden, 
but generally the progress of the disease is marked by a distinct 
set of symptoms ; and authors, since the essay of Dr. Whytt, 
have generally admitted the existence of three stages of hy- 
drocephalus. These divisions, although founded in nature, and 
highly useful in practice, will often be very irregular in their 
progress, and thus, at times, will render it difficult to assign 
with precision the symptoms which arise to their proper stage. 
A close watching of the symptoms may, notwithstanding, ena- 
ble us to obtain a sufficiently accurate knowledge of the exist- 
ing state of the disease. Dr. Cheyne and others have proposed 
modifications of the divisions of Dr. Whytt, founded, as it was 
intended, more on physiological principles ; that of Cheyne is 
divided into the stages of excitement, torpor, and of convulsion, 
while Itard* makes two, the first of irritation, the second of 
compression. 

The division of three stages, when considered as founded 
on the pathology of the disease, is the most practical, as having 
different causes for the production of their peculiar symptoms, 
and consequently requiring treatment appropriate to the re- 
moval of these causes. 

The first is the stage of simple irritation, and may be known 
by the usual indications of an irritable state of the brain, as ex- 
treme wakefulness, starting and grinding the teeth when asleep, 
and suddenly awaking with a loud scream and the appear- 
ance of fright. There appears to be a sudden feeling of dis- 

* Diet, des Sciences M6d., art. Hydrocephale Aigue. 



512 DISEASES OF CHILDREN. 

tress at times in the head, producing a violent cry, where both 
parts of the cry are acute and shrill, and described by M. Mau- 
noir, and Coindet of Geneva, as peculiar to this disease, and 
designated by the name of " hydrencephalique." This condi- 
tion often continues for four or live weeks, and even longer, and 
may often disappear without passing into the other stage. The 
excitement, however, attendant on indigestion, or irritation of 
any kind in the stomach and bowels, the invasion of any pul- 
monary disease, suppression of cutaneous eruption, habitual 
discharges, the sudden application of cold to the surface, or the 
continued irritation of teething, may increase the irritative ac- 
tion of the brain, until an inflammatory action has commenced 
in the meninges. 

Among other symptoms, at this period, is the functional de- 
rangement of the stomach and bowels, such as indigestion, 
irregularity of appetite; with other instances of a deranged ac- 
tion in the digestive viscera, of a character the most opposite, 
such as constipation, and at times diarrhoea. Most commonly, 
however, the former exists. The liver gives evidence of de- 
rangement in its secretory function. At first, a great deficiency 
of bile exists ; but as the disease advances, and the symptoms 
of inflammatory action become decided, an increase of secre- 
tion occurs, and free discharges of green bile takes the place 
of the constipation. 

Vomiting is a remarkable symptom, and whenever a sudden 
discharge of the contents of the stomach takes place, and con- 
tinues after the administration of the usual remedies for the re- 
lief of such symptoms, mischief in the brain may be suspected. 
A remarkable characteristic of this vomiting is, that it appears 
to be unattended with nausea, or the usual appearances on the 
tongue, indicating an idiopathic affection of the stomach. 
Another characteristic of vomiting from this cause is, that it 
more frequently occurs when the patient is raised, rarely while 
recumbent. The obstinacy of the vomiting, and existence of 
headache in infants, may be suspected by their sharp cries ; and 
in older children, their complaints will sufficiently point out its 
nature. These symptoms of incipient hydrocephalus ought 
to be carefully ascertained ; for upon a prompt discovery of the 
early stages of the disease, the successful treatment almost en- 
tirely depends. 

The second, or inflammatory stage, is indicated by the in- 
crease of the symptoms above mentioned, and in very young 
infants may, by the careless observer, be like those of the first 
stage, rather ambiguous, if we except that of vomiting, and 
other derangements of the primse viae. 

The tongue is generally white if the inflammation runs high, 



NERVOUS SYSTEM. 513 

and is an idiopathic affection; if, however, it arises from sympa- 
thetic irritation, from a disordered or inflamed condition of the 
stomach and bowels, it becomes dry, and covered with a dark 
brown fur. There exist great restlessness, irritability, and an 
increased sensibility to the light, the eyelids being partially 
closed and the brows contracted. The pain in the head is in- 
tense, and is more severe when the inflammation has been caused 
by a fall or a blow, and is a tolerably accurate indication of the 
degree of inflammation. The mechanical movement of the 
hands to the head will point out the seat of the pain, which 
is sometimes at the back part, sometimes at the front, or in the 
temples ; and children will often keep their hands on the part, 
and not suffer them to be removed even for a moment. The 
pain and distress cause great restlessness, tossings, and con- 
tinued wakefulness. These symptoms, however, are not always 
constant, but intermit, and are alternated with vomiting, and ab- 
dominal pains of a violent but transient character. The face 
for the most part is pale, but occasionally with a redness of 
one cheek. 

It is in the period of inflammation that the cry above alluded 
to, as characteristic of the disease, becomes most peculiar and 
constant. M. Mathey* describes its peculiarity to consist in a 
piercing, prolonged sound, but without indicating violent pain. 
It is only found in acute hydrocephalus, and not in any other dis- 
ease ; and when taken in connection with the altered state of the 
physiognomy, points out the condition of the brain connected 
with hydrocephalus, and is more expressive of a morbid dis- 
tress or terror than of acute pain. Although children cry in 
every disease of an acute and painful nature, yet this fact does 
not diminish the importance of this diagnostic sign, as these cries 
are rather of an impatient or fretful character, and with a little 
attention may be distinguished from the peculiar sharp expres- 
sion of suffering in hydrocephalus. 

Delirium is not very frequent at the commencement of this 
stage, but almost always exists towards the latter part. It is 
not of a ferocious character, and the child, if old enough to 
understand and converse, is easily aroused. 

The circulation in this stage is somewhat quickened, and the 
pulse is frequent and tense ; the skin continues but little altered 
in temperature, which is something above the healthy standard, 
and destitute of moisture. The condition of the pulse, at differ- 
ent periods of the disease, has been very accurately noted by 

* Me"m. sur l'Hydroce'phale, qui a remporte le Prix au Jugement de l'Academie 
de Dijon, le 4 Juiliet, 1818, p. 46. 

65 



514 DISEASES OF CHILDREN. 

Dr. Whytt ; but the extent to which he has carried his views 
render them of little avail in practice. 

Sighing is a constant and very remarkable symptom of the 
disease towards the termination of the inflammatory stage, and 
may be regarded as a very unfavourable one, as it commences 
immediately before the appearance of symptoms indicating the 
third, or stage of effusion. 

The last, or stage of effusion, is that from which the disease 
has received its name, and at this advanced period may almost 
be regarded as incurable ; hence the opinion of those who for- 
merly wrote on it, Whytt, Fothergill and others, that it is an 
incurable disease, from having only apparently recognised it in 
the last stage, without any knowledge of the inflammatory con- 
dition which preceded it, and upon the treatment of which the 
success almost entirely depends. In this stage the most promi- 
nent symptom is drowsiness, or a greater or less degree of stu- 
por ; indeed, it is an invariable attendant on the state of effu- 
sion. Its duration is various, and has even continued for the 
space of two weeks. When this is the case, it alternates with 
spasmodic affections and lucid intervals. At other times the 
attack of effusion is sudden, and has been well described by 
Dr. Golis under the significant name of water stroke. Cases of 
this nature have been noticed by every practitioner of any ex- 
perience. 

When this stage comes on in its most usual manner, after a 
period of active and well-marked inflammation, confusion of 
mind shows itself at first, rather than violent delirium, accom- 
panied with a peculiar expression of countenance, indicating a 
great derangement of the perceptive powers. The child is in 
a state of stupidity when aroused, which gradually becomes 
more difficult to effect, until he is at last completely comatose, 
and cannot be made to manifest any consciousness. A perfect 
torpor ensues in the latter part of the disease in every organ of 
sense ; the sight is entirely lost, and deafness becoming more 
and more profound, marks the progress of the compression on 
the origin of the nerves. The sense of feeling is the last which is 
lost, and, as might be supposed, where the effusion is in the brain 
alone, the lower extremities retain longest their power of motion. 

In the early periods of the stage of effusion, the eyes give 
some very important signs of the progress of the disease. 
The conjunctiva is suffused with blood, and while the child 
sleeps, the eyes are turned upward. The state of the pupils is 
that which has most attracted the attention of physicians, for it 
is a clear indication of the progress of the effusion. They may 
be enlarged even in the early stages of hydrocephalus ; but this 
condition is not permanent, and it is easy to discover whether 



NERVOUS SYSTEM. 515 

it arises from a certain species of irritation alone, by placing a 
light before the eyes ; the pupils will contract and immediately 
enlarge on the removal of the light. Then, again, by leaving 
the light some time before the eyes, the pupils will alternately 
contract and dilate, from what appears to be a convulsive move- 
ment of the iris. 

When, however, there exists effusion in the ventricles of the 
brain, the enlargement of the pupil is permanent, and the eye 
remains insensible to the light. This symptom is a fair indica- 
tion of the existing condition of the brain ; for it is more com- 
pletely marked towards the close of the disease, when compres- 
sion has destroyed the remains of sensibility. Strabismus is 
almost always a symptom of the disease ; more commonly 
occurring, however, at the commencement of the effusion, and 
usually precedes paralysis or convulsions. 

When a paralyzed condition of the muscles occurs, it is 
sometimes confined to one arm or one leg of the same side, or 
to the muscles that move the eye or elevate the palpebral. Be- 
fore a permanent paralysis occurs, a throwing of the arm of 
one side, irregular movements of the muscles of the face of 
that side, and the apparent want of entire control over the mo- 
tions, already show the existence of a partial paralysis. The 
paralysis comes on gradually, first showing itself as an apparent 
debility, until the power of moving the limb or limbs is entirely 
lost. 

Convulsions almost invariably occur, to a greater or less ex- 
tent, in hydrocephalus. Sometimes they are confined to one 
arm or leg, even when they have already suffered paralysis ; or a 
simple spasmodic twitching of the muscles of the face, or an irre- 
gular rolling of the eyeballs may alone exist. At other times they 
are general, and exist towards the termination of the disease, 
and the child not unfrequently dies in a convulsive paroxysm. 

In this stage the pulse is variable, according to the extent of 
pressure on the brain. If there exist much drowsiness and stu- 
por, it is slow and full ; these symptoms not usually prevailing to a 
great degree at the commencement of the effusion. A remark- 
able quickness is observed in the pulse, which continues, if con- 
vulsions or partial paralysis take the place of the stupor, gra- 
dually becoming weaker, until its beatings are imperceptible. 

Dr. Whytthas considered slowness of the pulse as a pathog- 
nomonic sign of effusion in the brain ; but this is not always 
so, for it is found to differ in many patients, although dissection 
has revealed the existence of serum in the ventricles. The 
condition of the pulse will in general be found dependent on 
the extent of the pressure on the brain. Besides, in young 
children, the circulation appears to be so susceptible of changes 



516 



DISEASES OF CHILDREN. 



and irregularities from very slight causes, that, as Harris has 
long since remarked, the condition of the pulse is not so per- 
fectly to be relied on in them as in older children or adults. 

The skin, at the commencement of this stage, is usually hot 
and burning ; as it advances, a dripping moisture covers the 
whole surface of the body, and almost every other symptom of 
complete prostration exists, the child either dying in this state, 
or a violent paroxysm of convulsions closes the scene. 

A peculiar condition of the system exists a short time before 
death, which all authors have mentioned, and which must have 
been noticed by every practitioner ; it is that which produces 
an almost complete remission of the symptoms of oppression ; 
and, in some instances, so complete is the relief, that the child 
will, from being insensible to all surrounding objects, become 
restored to the use of his sight, hearing, speech, etc. The re- 
lief is at times so great as to give the most flattering hopes of 
a favourable termination, that even the experienced physician 
can scarcely bring his mind to the belief that it is a deceitful 
brightening, preceding a more profound state of coma, inva- 
riably terminating in death. 

This is the ordinary course of the invasion, progress and ter- 
mination of hydrocephalus ; but it is not always that the disease 
observes such regularity in its progress ; and when the effusion 
occurs suddenly, the precursory symptoms are very transient, or 
are absent altogether. Although there will always exist some 
evidences of ill health, the digestive organs being those which 
are observed to be the most deranged, and often in that varia- 
ble condition so common in irritation of the gastro-intestinal 
mucous membrane, and with the itching of the nostrils, grind- 
ing of the teeth, that frequently attend this state of the stomach, 
yet there are cases where there scarcely appears to be any 
marks of disease whatever, either in the abdominal viscera or 
brain. Dr. Rush has recorded cases where there was not even 
pain in the head, and where the usual symptoms of nausea, 
dilated pupil, and strabismus were absent.* There are others 
having no other precursory symptom than a catarrh. In such 
cases the urine appears to be passed with difficulty, in a very 
small quantity, and is described by M. Coindet as being fari- 
naceous, or chalky. A drowsiness, with very slight febrile exa- 
cerbations, are the only symptoms of the disease under these 
circumstances. 

As might be supposed, there are different degrees of severity 
in these symptoms, and a great variety in the appearances of 
the disease, arising from the different temperaments in the indi- 

* Med. Inq., vol. ii. p. 210. 



NERVOUS SYSTEM. 517 

viduals affected. Thus, we may expect to find in one where 
the sanguineous temperament predominates, violent inflamma- 
tory symptoms, quick, hard pulse, violent headache, with occa- 
sional delirium ; in one of a lymphatic temperament, a greater 
degree of stupor will exist from the commencement, accompa- 
nied with a slow pulse and with but little febrile action. 

The diagnosis of this disease is in some cases difficult ; for al- 
most all disorders of the bowels, as well as the irritation of 
teething, will produce symptoms bearing a close resemblance 
to those of hydrocephalus, such as coma, strabismus, spasms, 
startings in sleep, etc. These, however, are confined to the 
last stage ; and when they are found to exist without the usual 
premonition, an immediate attention to the condition of the 
bowels may relieve all the untoward symptoms, and enable us 
to make a correct diagnosis of the disease ; for it not unfre- 
quently happens that a free alvine evacuation, or a simple inci- 
sion of the gums, will remove every symptom of cerebral dis- 
order. 

Dr. Cheyne* considers the appearance of the alvine evacua- 
tions as affording a good diagnosis of the disease, when it is 
liable to be confounded with intermittent fever of young children. 
In the inflammation of the arachnoid membrane which precedes 
the condition constituting hydrocephalus, they, are of a dark 
green colour and slimy consistence. In the last mentioned 
disease, also, as observed by Dr. Golis.f the abdomen is al- 
ways in a collapsed or flattened state, while in the febrile affec- 
tion just referred to, it is tense and swollen. In arachnitis the 
head is the hottest part ; in the remittent febrile affection of 
children the abdomen is hot, while the head is comparatively 
cool. In this disease, also, or worm fever, as it is generally 
known and described by authors, the inner surface of the nose 
is moist, the smell is acute, and there is a great itching of the 
part; in acute hydrocephalus the discharge from the nose is 
stopped, and the patient gradually loses the sense of smell. In 
this disease, also, the eye is very sensible to the light during the 
inflammatory period, and perfectly insensible to it after the 
effusion has taken place. In the intermittent fever from gas- 
tric irritation, the patient never complains of a strong light, 
nor is there a state of insensibility to the light at the termination 
of the disease, nor does there exist any paralytic affection at 
the approach of death, as in the state of effusion in hydroce- 
phalus. 

The work of Dr. Golis, a very excellent and practical mono- 
graph on the subject, is needlessly minute on the subject of the 

♦ Op. Cit. t Op. Cit., p. 53. 



518 DISEASES OP CHILDREN. 

diagnosis of the disease, in making distinctions between the 
various affections of a febrile nature with which children are 
so often attacked, when, in reality, the symptoms are evidences 
of a similar condition of the cerebral meninges, generally ending 
in effusion. The detail of the shades of differences occurring 
in the diseases with which it is liable to be confounded, rather 
tend to perplex than assist the practitioner — a variety of symp- 
toms depending on various occasional causes not unfrequently 
occurring in every disease, which, if always taken into account, 
to raise a doubt as to its indentity, would indeed make the 
diagnosis in some instances a matter of complete uncertainty. 
Other writers, Itard, Bricheteau, etc., have also extended their 
investigations to a minuteness in giving the symptoms of other 
inflammatory affections of the brain, which can scarcely ever 
be applied to any practical use. 

Without, therefore, going further into a detail, it is sufficient 
for all practical purposes to know, that when children are old 
enough to describe their feelings, there are good grounds for 
suspecting the disease to be present when they complain of 
severe pain in the head, accompanied with frequent pulse and 
frequent vomiting, especially on being raised in bed. Even 
then, it is not always easy to decide whether the symptoms 
are those occurring in the first stage of the disease in question, 
or that with which it may be so easily confounded — the re- 
mittent fever of infants. In a practical point of view it is but 
of little moment ; for if the symptoms of cerebral derangements 
in the last mentioned disease are so violent as to create a doubt 
as to its precise nature, no injury can possibly result from an 
error in regarding them as directly tending to the effusion of 
serum, and adopting a vigorous course for the prevention of 
this almost certainly fatal termination of the disease; indeed, it 
is, under these circumstances, nothing more than secondary or 
sympathetic hydrocephalus. In younger children, the physi- 
cian may also have reason to suspect the existence of the 
forming stage of the disease, when they are observed to cry 
incessantly, pass a long time without sleep, and the usual 
symptoms of violent pain in the bowels, such as writhing and 
drawing up of the legs, are absent ; when they have irregular 
alvine evacuations, vomiting, and a diminished quantity of urine. 

Hydrocephalus is always to be regarded as a disease of the 
greatest danger, and, when arrived at the stage of effusion, is 
almost necessarily fatal. Thompson says he never saw a pa- 
tient recover from it. Cheyne, Golis, and other writers, also bear 
testimony to the great mortality of the disease. Dr. Eberle 
states, that in the course of twenty years practice, he never 
knew but two fully developed cases which terminated in health. 



NERVOUS SYSTEM. 519 

In a great number of cases coming under my observation in 
the course of several years, I know of but one recovery where 
effusion had actually occurred, and this was a case where every 
hope of recovery had been abandoned, and where a sudden 
and very copious discharge of urine came to the entire relief 
of the patient. The prognosis is more favourable, other things 
being equal, in proportion to the early period of the appearance 
of the disease, at which it is subjected to medical treatment ; 
and the earlier prompt and judicious remedies are applied, the 
more hope is there of recovery. 

Morbid Anatomy and Pathology. — Authors have been 
very particular in recording every appearance of disease in 
the brain, on post-mortem examinations. On this account it is 
that the appearances have been described as very various ; and 
while the effusion of serum has been regarded as its peculiarity, 
tubercles, cysts, suppurations, sanguineous effusions, adhesions, 
and other changes, have been carefully noted whenever they 
have occurred. M. Bricheteau considers this minuteness as an 
unnecessary accumulation of isolated facts, and that the record 
of the occasional departure of the disease from its strict noso- 
logical place, gives evidence of but little discernment in the 
various affections of the brain, in regarding them as essential 
to the disease in question, which in strictness is an accumula- 
tion of serum in the cavities. But it is clear, that in a practical 
point of view these facts are of the greatest importance ; and in 
so far as pathology can clear up the mystery of disease, go 
much towards affording a correct knowledge of the nature of 
hydrocephalus, as they give unequivocal evidence of the exist- 
ence of an inflammatory period, which, from dissection, could 
not be proved from simple effusion of serum. 

The most common appearance, on dissection, is a quantity 
of serum in the lateral ventricles of the brain, varying in quan- 
tity from two to eight ounces ; occasionally, however, the 
quantity has been found to be much greater, even to the ex- 
tent of twenty-four ounces, according to M. Brachet, in the 
other ventricles and base of the brain. On other occasions, 
but little or no serum is found in the ventricles, but between 
the membranes. It is a limpid fluid, resembling whey, and is 
not coagulable by heat like the effused serum of other cavities. 
Although usually clear and colourless, yet it is sometimes turbid 
and yellow, and occasionally mixed with albuminous flakes; 
at other times it is of a gelatinous consistence between the con- 
volutions of the brain. 

The substance of the brain, according to the dissections of 
Laennec, Golis, Jadelot and Bricheteau, is often of a firm con- 
sistence, and in some degree, as" it were, hypertrophied ; where 



520 DISEASES OF CHILDREN. 

this is the case, there is but little effusion in the cavities. In 
other instances there exist great disorganization and softening; 
this is more particularly the case where there has been a large 
quantity of effusion, by which the brain has been exposed to 
compression. In some, on the contrary, a part will be found 
completely indurated. Pus has also been found on the surface 
of the brain, of which Abercrombie has given two cases,* that 
followed the usual symptoms of hydrocephalus. 

Besides effusion in the ventricles, and alterations in the con- 
sistency and organization of the brain, the pia mater and tunica 
arachnoidea, as well as the adjacent cellular tissue, are for 
the most part the seat of the usual marks of inflammation, such 
as sanguineous injections, or exudations of albuminous matter on 
their surface. The plexus choroides is always dark red, and 
in some instances enveloped in a thick coating of albumen. 

The veins and sinuses of the brain also partake of the dis- 
eased alterations, for they are always found engorged and 
distended with blood. 

In addition to these appearances of disease in the brain, the 
abdominal viscera show the existence of disease, which has, by 
sympathetic irritation, caused the cerebral affection. Brachet, 
Sabrioles, Senn, Cheyne and Yeats, note particularly the in- 
flammatory appearances of the intestines. The two latter, 
especially, have remarked the congested state of the liver. 
Some have strangely attributed these appearances in every 
instance to the excessive use of purgative medicines, when all 
the symptoms on the original invasion of the disease are suffi- 
cient proofs of the deranged state of these organs. It is fre- 
quently found that the mucous membrane of the intestines is in 
a state of inflammation ; and, from the alterations in the calibre 
of some of the intestines, there exist the most undoubted proofs 
of a previous state of inflammation. 

Among other conditions of the brain in this disease, which 
the investigations of modern pathologists have brought to light, 
is the presence of tubercles. These depositions of tuberculous 
matter, until within a few years, were scarcely suspected, 
although, in fact, according to the results of the dissections of 
Dr. Green, they occur in one fourth of the number of children 
dying of cerebral diseases. f It has indeed been long noticed, 
that children dying of hydrocephalus were mostly of a scrofu- 
lous temperament, and this condition has been shown to exist 
by the dissection of a number of cases by Dr. Mills; J but the 



* Patholog. and Pract. Researches of Dis. of the Brain; Edinb., 1828. 

■t London Lancet, Loc. Cit. 

Z Trans. King and Queen's College, vol. v. p. 350. 



NERVOUS SYSTEM. 521 

positive proof of this affection being present in any of its forms, 
was unnoticed, until the subject was brought into notice by the 
essays of MM. Mitivie, Giraud, Tornelle, Levielle and Defour, 
in France, referred to by Dr. Green, in the essay above men- 
tioned, and by Dr. Gerhard, of Philadelphia, in the American 
Journal of Medical Sciences.* The latter has drawn his cases, 
also, mostly from the Parisian hospitals, which are filled with 
patients who have suffered much from insufficient and bad 
nourishment, and also from impure air, a class of subjects where 
we might, expect to find the effects of a degenerated condition of 
the fluids ; and the inference which he appears to draw as to the 
nature of the disease called hydrocephalus acutus and meningi- 
tis, in regarding it as a tuberculous disease, is scarcely applica- 
ble to other cases of the disease. These tubercular deposits 
have often been found in children who have not manifested 
any cerebral disturbance during life, and have even attained a 
considerable size without producing any symptoms of inflam- 
mation; in other instances small tubercles have been dis- 
covered, evidently the cause of very great irritation and inflam- 
mation, effusion and death; proving them to be a cause of 
inflammation, and thus one of the sources of serous effusion. 
In eighty cases collected by Dr. Green in the paper above 
mentioned, the maximum number of tubercular formations 
occurred between the ages of two and four years. 

It is evident from the detail of the symptoms, and the appear- 
ances on dissection, that the effusion constituting the disease is 
a secondary affection from previous inflammation of the mem- 
branes of the brain, which itself is consecutive on affections of 
the abdominal viscera, except in those cases arising from some 
direct cause. The varying appearances on dissection prove 
this beyond a doubt, especially when considered in relation to 
the pathognomonic symptoms, which are clearly those of cepha- 
litis, when observed before the final stage of effusion. These 
views were the opinions of our distinguished countryman, Rush, 
and of Henke, Stark, Sprengel, Golis and others. From nume- 
rous dissections made by Golis, and still more recently by Bil- 
lard, this inflammation, or meningitis, as it is termed by the last 
mentioned author, appears under two forms, that of a simple 
inflammation, with nothing more than a vascular injection or 
spotted redness, with or without the formation of a pellicular 
concretion or false membrane. Under these circumstances, 
convulsions and violent cries are the symptoms that are the 
most common. The other form is that which marks the 

♦ Vols. 13th and 14th. 
66 



522 DISEASES OF CHILDREN. 

disease we are now considering, and known by the presence 
of serum or sero-purulent fluid in the cavities of the brain. 
This state of the brain is known by the symptoms already 
described, and in the primary stages are those which are pe- 
culiar to simple inflammation of the meninges. These symp- 
toms, it is true, are often very various as respects their duration, 
intensity and exacerbations ; but whatever be their varieties of 
form, their fundamental character always exists ; and it will 
not be a difficult thing for the practitioner to detect the disease 
from the characteristic phenomena which inflammation of these 
membranes exhibits. 

In those cases in which effusion appears to be very sudden, 
causing the immediate death of the patient, it has been thought 
by some that the suddenness of the effusion is only apparent. 
This variety has been known by the names of apoplexia hy- 
drocephalica, hydrocephalus hyper-acutus, and described by 
Dr. Golis under the term of water stroke, from the suddenness 
with which the symptoms appear. Dr. Golis describes it as 
passing through the stages of turgescence and inflammation, 
without giving the usual evidences of their existence, and that 
the stages of transudation and palsy, four stages being his divi- 
sion of the subject, are also confounded together, and cannot 
accurately be distinguished. He has, notwithstanding this 
apparent absence of the periods of excitement, discovered upon 
dissection traces of turgescence and inflammation. The effused 
fluid was always found turbid, with much less coagulable 
lymph than in ordinary hydrocephalus ; a circumstance which 
led him to the opinion that lymph was partly mixed with serum, 
and that the whole mass was the product of a morbid action of 
the vessels. The effusion, therefore, may have occurred slowly, 
and not have produced its peculiar effects until it had become 
abundant ; such is the opinion of Billard, and appears to be 
supported by daily experience and by natural analogy. 

Treatment. — In the treatment of this disease it is of the 
greatest importance to take into consideration the circumstances 
which have preceded and which accompany the attack, for the 
successful management of it depends not only on the early ap- 
plication of suitable remedies for present symptoms, but also 
on the nature of the exciting cause, for a prompt removal of 
this is our main dependence for the cure. 

As the disease is naturally divided into idiopathic and symp- 
tomatic, an early inquiry into the immediate cause of the cere- 
bral disorder in children, will enable us to apply the appropriate 
remedies, and at once use such means as are the best calculated 
to extinguish the disease before it has got its fatal hold. When 



NERVOUS SYSTEM. 523 

its cause is one which has acted directly on the brain, such as 
exposure to excessive heat, falls, or blows on the head, or when 
the inflammation has been produced by obstructed perspiration, 
the indications are, 1st, to relieve the excited state of the blood- 
vessels of the brain ; 2dly, to allay any general febrile excite- 
ment, by which the circulation in the brain is maintained in an 
excessive state of action ; and, 3dly, to produce such revolutions 
as will create a permanent flux of blood from the affected part. 
Nothing is so effectual for fulfilling the first indication as the 
prompt abstraction of blood from the arm, and the quantity 
taken should be sufficient to produce a decided effect on the 
general system. The pulse, in the state of active inflammation, 
is usually hard and frequent, and an impression on the force of 
the circulation by the drawing of blood is essential to the ma- 
nagement of the case ; indeed, there is nothing that can take the 
place of general bleeding, in a disease of so great danger as 
inflammation of the brain, and one which will not allow of the 
slightest waste of time in the use of other and comparatively 
trifling remedies. If it be not vanquished at the commence- 
ment, and the inflammatory action at once extinguished, there 
exists but little hope of carrying the disease to a successful ter- 
mination ; the march of inflammation in children is so rapid, 
the termination in effusion, where the inflammation is seated in 
the arachnoid membrane, so certain, that our only hope is to 
arrest the inflammation by the only efficient means above men- 
tioned. To be the most effectual it ought to be performed at 
the commencement of the inflammatory symptoms, and carried 
to a sufficient extent to produce a disposition to syncope at first. 
When it is necessary to repeat the operation, some care will 
then be required in regulating the quantity to be taken, for 
serious and even fatal convulsions may ensue from incautiously 
carrying the loss of blood to the extent of producing a con- 
tinued tendency to fainting in young children. On the recur- 
rence, therefore, of reaction, the vein may be again opened, 
and it will generally be found that, compared with the first 
bleeding, a small quantity will affect the momentum of the cir- 
culation. Dr. Mills* recommends the drawing of blood by 
leeches immediately after venesection, as decidedly more effi- 
cacious than venesection alone ; or the local abstraction of 
blood by leeches alone, which has been so strongly recom- 
mended in continental Europe, and almost generally adopted 
there. In the use of so important a measure as blood-letting, 
reference ought in all cases to be had to the constitutional vigour 

* Trans, of the King and Queen's College of Physicians, in Ireland; vol. v. 
p. 457. 



524 DISEASES OP CHILDREN. 

of the patient, and, whether performed by venesection or leeches, 
should never be persevered in until exhaustion is produced. 
There will be but little hazard of serious effects resulting from 
blood-letting, if it be performed promptly upon the first appear- 
ance of sanguineous turgescence, before the general circulation 
has largely participated in the disordered action, and before the 
heat from over-excitement has become predisposed to yield to 
a serious collapse from the loss of blood ; nothing, therefore, 
can compensate for the loss of the first few hours where this 
remedy is withheld. 

The next means for the fulfilment of this indication is the use 
of purgative remedies, and which, from their powerful influence 
on the whole secretory apparatus of the alimentary organs, 
strongly tend, at the same time, to fulfil the second indication, 
and are almost indispensable measures whenever the circulation 
requires to be controlled. Whenever the usual evidences of 
inflammatory irritation in the mucous membrane of the bowels 
are absent, as is the case in the disease in its purely idiopathic 
form, an active cathartic may be given without hazard, and to 
insure its good effect it ought to operate promptly. For this 
purpose, a solution of some neutral salt or infusion of senna, or 
calomel, combined with jalap or rhubarb, will be found the most 
suitable purgative. Whatever be the precise article selected, 
or the particular mode of its administration, it will, if active in 
its operation, exercise a powerful effect in addition to bleeding, 
in arresting the developement of inflammation in the meninges 
of the brain at the early period of the disease. 

In connection with these means, which have a direct effect 
in fulfilling the two first indications of cure, antimonials have 
also been used with much success by Laennec in France, and 
Dr. Stoker of Dublin. The former gave tartar emetic, and 
the latter, James' powder, to control the activity of the circu- 
lation, and thereby lessen the proportionate action in the brain. 

The application of cold directly to the scalp, is a very useful 
means of arresting the excessive action of the blood-vessels in 
the brain. It has been supposed by some, that the effect of this 
agent would rather be the reverse of controlling the activity of 
the blood-vessels within the cranium, by constricting the capil- 
laries', and thus increasing the inflammation from the crowding 
of the larger vessels, and those not immediately under the in- 
fluence of this therapeutic agent. But experience proves these 
objections to be without foundation, and that it is one of our 
most powerful measures for the treatment of the disease, as it 
lessens the action of all the blood-vessels in these parts, by its 
action on the carotids, from continuous sympathy. 

In addition to these measures, that of revulsion on the lower 



NERVOUS SYSTEM. 525 

extremeties ought by no means to be neglected. A stimulating 
pediluvium is one of the best ; but the use of this and other re- 
vulsive remedies will be considered more at large when we 
come to the subject which is of more frequent occurrence in 
children, that of the ordinary form of hydrocephalus, arising 
from a deranged state of the digestive and chylopoetic viscera ; 
the inflammation occurring in the meninges under these cir- 
cumstances, and preceding the effusion of serum, requiring 
nearly the same treatment as an idiopathic inflammation of the 
part. 

It is of the greatest practical importance that the origin of 
ordinary cerebral affections in children should be constantly 
kept in view, that the disease in its incipient stage may be 
promptly met by appropriate measures ; for upon this very 
materially depends the success of the treatment. If inflamma- 
tion has commenced, it is indeed difficult, and in too many in- 
stances impossible, to control its course, and to prevent its run- 
ning into the stage of effusion. The strong tendency, therefore, 
to cerebral disorders, when there exists a continued derange- 
ment of the digestive viscera, ought to be the subject of the 
physician's fears, that by timely remedies, of a nature which 
experience has proved to be of undoubted efficacy, the fatal 
progress of the disease may be prevented. In this disease, more 
than in any other, the anticipating method must take the place 
of that baneful mode of practice known as the expectorant 
method. 

The early, or forming symptoms of the disease, are often en- 
tirely overlooked and neglected ; and it is not until the languor, 
and general paleness of the whole surface, together with the 
evidences of gastric and intestinal derangement have, after a 
continuance of some time at least, ended in heat and tumes- 
cence of the head, that the disease is for the first time suspected, 
and much valuable time is lost by the delay. It is to attack 
the disease at this period, on which Dr. Yeats so much insists, 
and on which the safety of the patients often rests. He judi- 
ciously remarks, that if we proceed upon the principle that the 
disease is only in the head, we shall be constantly exposed to 
disappointment, and to unavailing regret for the commission 
of errors. 

Regarding the disease, therefore, in its ordinary form, as con- 
sisting of three stages, the indications are, in the first stage, or 
period of abdominal irritation, to restore the healthy action to 
the chylopoetic viscera ; in the second, to allay the violence of 
the inflammatory action, to control the febrile condition of the 
system, and to divert the current of fluids from the brain. In 
the third stage, that of effusion, our efforts may be almost re- 



£26 DISEASES OP CHILDREN. 

garded as hopeless ; yet as recovery has sometimes taken place 
under the most unpromising circumstances, we may still attempt 
the removal of fluid by establishing discharges from the capil- 
laries by blisters, or by the vicarious evacuation of urine. 

We are indebted to the enlarged views of Dr. Cheyne for 
the first clearly suggested opinion that our treatment must, in 
the forming stage of hydrocephalus, be directed to the ab- 
dominal viscera, and especially the liver ; the deranged secre- 
tions of which, manifested in the morbid appearances of the 
stools, give a certain indication that here is to be found the true 
origin of the disease. In many cases there is a tenderness in 
the right hypochondrium ; this, together with the dark green 
and unhealthy appearance of the bile, demands the use of mer- 
curial cathartics for the purpose of eliciting a free discharge of 
the biliary secretion. The foetid condition of the breath, and 
the yellow, or dark appearance of the tongue, more particularly 
indicate the cases in which calomel may be freely used. If, 
however, there should be much soreness manifested on pressing 
on the region of the liver, leeches should be applied, or if there 
be much general excitement, blood should be taken from 
the arm. Calomel has been found, by all practical men, remark- 
ably efficacious in the treatment of hydrocephalus, and it is, 
doubtless, from its influence over the seci'etory function of the 
liver, that its good effects are derived. It should therefore 
form the basis of the cathartic plan, which for the most part is 
indicated in the treatment of this disease, whether or not it be 
deemed necessary to associate blood-letting in the treatment of 
this stage. Golis directed a quarter of a grain to a child from 
one to four months ; from one to two grains to a child of six 
months to a year. Clarke gave one grain every six, four, or 
three hours, unless a diarrhoea should ensue. The adminis- 
tration, however, of repeated doses of medicine, especially of 
a cathartic nature, ought, if possible, to be avoided in young 
children, as its tendency is to keep up an irritative action in 
the mucous surface of the intestines, which children cannot 
well bear even for a short time. On this account it ought 
to be given in a full dose, and followed in a few hours by 
a small quantity of castor oil, or neutral salts.- As to the 
dose of calomel, it does not so much depend on the age in 
a disease -of so great danger as acute hydrocephalus, as upon 
the urgency of the symptoms, and the effect on the intestinal 
canal. Five to ten grains to a child from four to eight years of 
age, and from two to four grains for one between one and four 
years, will produce a full purging effect. 

In the use of cathartics, the appearance of the tongue and 
nature of the breath ought carefully to be examined ; and if the 



NERVOUS SYSTEM. 527 

former be found free from fur, clean, or red, and the latter desti- 
tute of odour, we ought to avoid the use of any medicine of a 
purgative nature, which would aggravate the irritation, or per- 
haps the inflammation of the gastric mucous membrane. When 
the tongue is red, and there is tenderness about the epigas- 
trium, cathartics must be avoided, and leeches applied over 
the affected part. In every instance where there exist much 
febrile excitement and tenderness of the hypochondrium, this 
excitement must first be allayed by the application of leeches 
to the part, or by venesection, before any advantage can be 
expected from the use of calomel. 

It occasionally occurs that the deficiency of constitutional 
vigour of the child forbids the use of blood-letting, and it may 
be necessary to substitute other measures to allay the increased 
action of the vascular system ; for this purpose James' pow- 
der, or antimony in some form, has been recommended by dif- 
ferent practitioners. Dr. Cheyne used antimony in combination 
with calomel, in cases of infantile remittent, which is very lia- 
ble to terminate in hydrocephalus. In cases which forbid the 
use of blood-letting, it would not be unattended with hazard to 
young children, especially in infants, to make use of antimony, 
and in place of it, ipecacuanha may be substituted in combina- 
tion with calomel ; a small quantity of ipecacuanha given with 
a few grains of calomel, and repeated every three or lour hours, 
until a free evacuation from the bowels ensues, would fulfil the 
most prominent indication at this period of the disease. This 
method ought, according to the judicious views of Dr. Cheyne, 
be persevered in until an alteration is visible in the stools. 
Where these measures fail in producing an alteration in the 
secretions, Dr. Cheyne, Percival and Brooks, all advise the use 
of opiates in some form ; they appear to be more applicable 
where the abdominal disease is connected with irritation in the 
intestines, and known more especially by the presence of ab- 
dominal pain relieved by pressure. It is not safe to give chil- 
dren, and especially those quite young, repeated doses of any 
simple opiate. Dover's powder, therefore, especially when com- 
bined with calomel, will be found eminently beneficial, both in 
allaying the irritation and determining the flow of fluids to the 
surface. The allaying of the morbid irritability of the nerves 
in children by opiates, is often of signal benefit when judiciously 
resorted to ; and decidedly the best form for its administration 
is the compound powder of ipecacuanha above mentioned. By 
the use, therefore, of cathartics and alteratives, with the occa- 
sional administration of a mild opiate, we may often allay the 
irregular excitement arising from abdominal derangement, 
which so frequently leads to inflammation in the brain, termina- 



528 DISEASES OP CHILDREN. 

ting in effusion ; and a seasonable interference of art may en- 
tirely arrest this formidable disease in its commencement, at a 
period when there appears but little if any danger. 

In the next stage the symptoms assume a formidable and 
well-known appearance, and demand the abstraction of blood 
both generally and locally. Our distinguished countryman, Dr. 
Rush, was early led to regard the origin of the disease as an 
inflammatory affection, and relied principally on copious vene- 
section for its cure ; he has recorded several cases of the suc- 
cess of this practice.* Blood-letting must therefore be our 
principal reliance, where turgescence, inflammation and pain 
in the head, constitute the most marked symptoms of the disease. 
Drs. Mills, Eberle, and other practical writers, bear testimony 
to the great efficacy of blood-letting, to be repeated upon the 
appearance of any return of inflammatory action. The re- 
marks already made on the extent to which bleeding is to be 
carried, are applicable to every form of inflammation of the 
brain, for the preternatural activity of the blood-vessels must 
be arrested, if we wish to prevent a fatal effusion ; and the prin- 
cipal difference in the treatment of idiopathic affections of the 
brain, and those arising from a disordered state of the chylo- 
poetic viscera, is in the order with which the remedies are used ; 
commencing in the latter with such as will directly affect the 
secretions of the viscera connected with digestion, and in the 
use of such as are known to exercise a more special influence 
upon the hepatic system. The abstraction of blood, also, from 
the right hypochondrium, will also be found at times a necessary 
preliminary measure in the treatment of the ordinary form of 
hydrocephalus. When, however, the disease has seated itself 
on the brain, and the symptoms of inflammation have made 
their appearance, there can be no difference in the treatment 
of the affection, for in both, bleeding must be our main depend- 
ence. Cold, also, must be applied to the scalp, by means of 
cloths wetted with iced water. When cold is employed, its 
effects should be carefully watched, for it may otherwise be 
carried to a dangerous excess. 

On the subject of revulsive remedies, there exists but one 
opinion as to their efficacy ; but a difference on the subject of 
those of an epispastic nature. They should never be used until 
after the activity o( the circulation has been subdued by pro- 
per evacuations, and even then the extreme irritation they pro- 
duce in children makes them a dangerous means. Stimulating 
baths to the lower extremities may be used with decided bene- 
fit, in connection with other measures. It is upon a steady per- 

* Med. Enq. and Observ., vol. ii. p. 53. 



NERVOUS SYSTEM. 529 

severance in these remedies, and a judicious application of them 
to the existing symptoms, that the disease is to be overcome ; 
for if the next stage, the treatment of which we are now to 
consider, succeeds, but little hope can exist for the patient. 

In the last stage the indication is to remove, if possible, the 
serous effusion. This may be attempted if there still appears to 
be much vascular excitement, by the continuance of local de- 
pletion, and by the use of mercurial cathartics, where there are 
symptoms of derangement in the abdominal viscera. The next 
method of effecting this is by the application of blisters, which, 
however, should never be used where much vascular action 
is present. When they are used they ought to be applied 
behind the ears or upon the back of the neck, and a free dis- 
charge maintained by means of stimulating applications. Great 
benefit has also been derived from dressing the blistered sur- 
faces with strong mercurial ointment. 

Hydragogue cathartics have also been resorted to with suc- 
cess, under the most unpromising circumstances ; a recovery 
has taken place when the symptoms of effusion had appeared, 
after giving half a drop of croton oil, given every two hours. 
In another instance, a spontaneous discharge of urine occurred 
in a child aged about six months, where all hopes of recovery 
had been abandoned; immediate relief of all the symptoms of 
cerebral oppression took place, and the child ultimately re- 
covered. A perseverence, therefore, in the employment of 
those remedies which will excite a copious flow of the urinary 
or intestinal secretions, would appear to be the duty of the phy- 
sician, even when the case appears to be hopeless. 

The sudden effusion, to which Dr. Go] is has given the signifi- 
cant name of water stroke, I believe is always fatal ; whether it 
is preceded by the slight evidences of cerebral excitement, 
manifested simply by exhilaration of spirits, which is its only 
premonition, or whether it arises as a complication of some 
cutaneous eruption, as measles, scarlet fever, etc. In both, the 
most close observations are unable to detect the inflammatory 
affection of the brain, on the treatment of which success almost 
altogether depends. The course to be adopted should be that 
used for the removal of the effused fluids mentioned above. 

CHRONIC HYDROCEPHALUS. 

Etiology. — This form of the disease appears to be connected 
with some irregularity in the progress of the formation of the 
brain ; for it is frequently of congenital origin, or shows itself 
for the first time at a very early period of infant life. It is 
difficult, such is the insidious manner of its approach, to tell 

67 



530 DISEASES OF CHILDREN. 

when the disease commences, unconnected as it is with the 
usual causes of hydrocephalic affections, or with any evident 
inflammation in the meninges. 

M. Billard* is of opinion that those cases which are congeni- 
tal, in all probability arise from an inflammation of the meninges 
during intra-uterine life, or of some malformation difficult to 
ascertain, resembling in some respects the nutritive hypertrophy 
of the brain. The latter idea receives some support from the 
developement of the brain and cranium in the icetus affected 
with hydrocephalus. The bones acquire a breadth and thick- 
ness, evidently showing an increase of nutrition ; and it has also 
been observed that those infants in whom the brain and cranium 
are very much developed, are very much exposed to hydro- 
cephalus. The vital activity, therefore, or the power of nutri- 
tion, ought to be regarded as one of the causes of the form of 
disease now under consideration. The activity in the nutritive 
process must almost of necessity increase the secretion from 
the membranes of the encephalon, and fill the ventricles, and 
even the surface of the organ beneath the cranium with serous 
fluids. 

Semeiology. — Chronic hydrocephalus is very insidious in its 
approach, and passes through its different stages in a very slow 
and gradual manner. When it appears to have made its in- 
vasion after the birth of the child, it shows itself by fits of 
languor and drowsiness, with but little, and often no febrile 
excitement whatever. Although usually attacking young 
children, it may occasionally affect those of more advanced 
age in a very insidious degree, and terminate in the enlargement 
of the head, which is known as the form called chronic. In 
the majority of those instances, however, which make their 
invasion after the period of infancy, there exist more or less 
symptoms of the inflammatory stage, such as hot skin and 
head-ache ; and it cannot, although gradual in its approach, and 
perhaps protracted and permanent in its effects, be regarded 
as the chronic form of the disease. 

As the effusion increases, the head enlarges sometimes to an 
enormous size, while the sutures separate, and the scalp cover- 
ing the fontanelles is projecting and fluctuating with fluid when 
pressure is made on the head. At an indefinite period from the 
first appearances of effusion, symptoms of oppression on the 
brain make their appearance. These first show themselves 
in the eyes ; strabismus, and dilatation of the pupils succes- 
sively occur ; the intellectual faculties become much impaired, 
and in proportion as the disease advances are entirely blunted. 

* Op. Cit., p. 467. 



NERVOUS SYSTEM. 531 

The locomotive power is gradually lost, the limbs at length 
become paralytic, or convulsed. The loss of nervous energy is 
evident in other parts of the system, for the bladder refuses to 
perform its functions unassisted, and the catheter is sometimes 
required to draw off the retained urine. All these symptoms 
may extend to a number of years, and the patient live to an ad- 
vanced age in a state of idiotism. There are, however, cases 
on record where the intellectual faculties have remained but lit- 
tle impaired, notwithstanding an excessive accumulation of fluid 
and a corresponding enlargement of the head. A case of this 
kind is mentioned by Dr. Monro ;* it was that of a child who 
was brought to St. George's Hospital, at the age of eighteen 
months, with a head very much enlarged. The size of the head 
steadily increased, until at the age of eight years it measured 
two feet four inches in circumference, and the forehead alone 
was half the entire length of the face. The head was exceed- 
ingly heavy, so that the child could scarcely preserve her ba- 
lance in walking. Her memory was strong and retentive, 
and she was as lively as children usually are at her age. 
Michselis,t also, mentions the case of a patient of the age of 
twenty-nine years, whose intellectual faculties were not in the 
least impaired, and who had been affected with the disease 
from his birth. 

Very often all the symptoms of chronic effusion appear at 
the time of birth, and the head has at times been so greatly 
enlarged as materially to interfere with parturition, and as 
much as four pounds of fluid have been evacuated from the 
head of a foetus after birth. Children born with this accumula- 
tion of water within the cranium, will usually live but a few 
months : the head acquires a large size, the sutures are wide- 
ly separated, and with other symptoms of oppression of the 
brain the child becomes paralytic, or dies convulsed. 

Pathology. — Chronic hydrocephalus consists in a great 
abundance of serum infused in the ventricles of the brain and 
arachnoid cavity. It is this which has made the distinction be- 
tween hydrocephalus interims and hydrocephalus externus, al- 
though the latter has indeed been applied to the accumulation of 
water between the integuments and the bone ; but this is clearly 
nothing more than dropsy of the cellular membrane, and not 
hydrocephalus ; but in some cases the fluid has accumulated 
within the cranium, and through some channel has passed into 
the cellular membrane, and distended the integuments. The 
quantity of fluid is sometimes very great ; firteen and even twenty- 

* Med. Trans., vol. ii. p. 359. 

t Medical Communications, vol. i. art. xxv. 



532 DISEASES OF CHILDREN. 

five pints of serum have been evacuated after death, where the 
disease has gone on steadily increasing.* 

In some instances there has been found an external tumour, 
where the bones of the cranium have been widely separated 
in hydrocephalus, through which the brain has protruded, form- 
ing a real hernia cerebri. This is clearly the result of the com- 
pression which the brain undergoes from the effusion of the 
serous fluid. The hernia may be satisfactorily ascertained by 
noting the situation of the tumour, as it always occupies a part 
corresponding to one of the fontanelles.f A remarkable case 
of this nature is recorded in the fourth volume of the American 
Journal of the Medical Sciences, by Dr. Homer, where the fluid 
had forced out the posterior lobes of the cerebrum through the 
posterior fontanelle. 

As was before remarked, chronic hydrocephalus, which ap- 
pears very early in life, is connected with some degree of mal- 
formation of the brain; and dissection reveals in such cases the 
existence of some imperfection, or defect in the organization, 
which is a remote cause of the disease. The brain, also, has 
been found in a spongy and fungous state.J and sometimes dis- 
organized so completely, as to present the appearance which 
has been of late described under the name of ramollissement, 
affecting at times both parts of the brain. The brain has been 
found partially absorbed, the part which it occupied being noth- 
ing more than a sort of pouch ; from the absorption of a por- 
tion of the brain, the effused fluid finds its way from the ven- 
tricles to the dura mater, in contact with the upper part of the 
cranium. || 

In general, the whole head increases in size. In some cases, 
however, there has been found an elastic tumour formed by the 
yielding of the dura mater, which gradually increases in size, 
until it becomes equal to the head. 

The bones of the cranium have in many cases become very 
thin, and being deprived of the calcareous part, have appeared 
to consist of scarcely any thing more than cartilage. 

There can exist no doubt that effusion of fluids may occur 
from a relaxed condition of the secernents, as well as from the 
excited action of those vessels ; but in the disease before us it 
appears to be evidently connected with the active state of the 
secernent vessels, dependent on the growth of the brain, and 
perhaps connected with a torpor of the absorbents. The fre- 
quent connection of the disease under consideration with a mal- 

* Bonnet, Sepulcho., Lib. i. sec. xvi. 
t Billard, Op. Cit., p. 471. 
t Conrad, Diss, de Hydroceph., Argent, 1778. 
11 Baillie, Morb. Anat. Fasic. x. p. 213. 



NERVOUS SYSTEM. 533 

formed state of the brain — a state of nutritive hypertrophy — - 
sufficiently proves these views. When this form of disease, 
however, comes under our notice, it can scarcely be regarded 
as one of activity ; we see it only in its consequences, and may 
compare it to the third stage of acute hydrocephalus ; but from 
its identity with the developement of the brain, the accommoda- 
ting powers of nature have enabled the parts to yield to this 
diseased state of things, and afford one of those numerous in- 
stances of the resistance of the system to dissolution at the 
early period of life. 

Treatment. — The treatment must be directed to the removal 
of the effused fluid, either by endeavouring to promote absorp- 
tion, or by evacuating it. Diuretics have been used, and Dr. 
Withering recommends particularly digitalis, a medicine which 
cannot be employed with safety in young children, from its de- 
pressing power on the circulation. Active purging cannot be 
advantageously used in this disease, and at the early period of 
life at which it usually makes its appearance. Calomel, as a 
tonic and alterative has been used, it is said, with advantage ; 
but of this I cannot speak from any experience. Blisters and 
issues have in some instances been followed by good effects — - 
rarely, however, when the disease is deep seated and extensive. 
A permanent drain established on the vertex is recommended by 
Dr. Mills. 

The cure of chronic hydrocephalus has been effected by Dr. 
Conquest by tapping the head ; in some instances, under the 
most unpromising and deplorable circumstances, where there 
was a total loss of sight, convulsions, etc. Of nineteen cases 
operated on by him, ten were cured: the quantity of fluid dis- 
charged varied from six to forty-eight ounces. Dr. Charles A. 
Lee lias given the results of this operation, where the child was 
so far restored as to perform the ordinary movements of the head, 
and suck freely on the twelfth day. For eight days it was 
doing well, when symptoms of accumulation appeared, and the 
operation was again performed. The child died on the twen- 
tieth day after the second operation, of cholera infantum.* 

There is a case recorded by Dr. Hofling.f of a boy, aged five 
years, cured of chronic hydrocephalus by accidental paracen- 
tesis. He received a kick from a cow which fractured the 
frontal bone, already extremely thin ; a quantity of serum flowed 
from the wound for eight days. Two years after this accident 
the. boy enjoyed good health, and the head bore but a proper 
proportion to the size of the body. 

* N. Y. Med. and Phys. Journal, vol. vi. p. 490. 
t Wochenscrift fur die gesammt Heilkunde, No. 41. 



534 DISEASES OF CHILDREN. 

From the belief that chronic hydrocephalus might at times 
result from a want of due resistance in the bony parietes of the 
head, compression has been resorted to by means of bandages 
and adhesive straps ; the former method was used by Sir Gil- 
bert Biane, and the latter by Mr. Barnard. Recently this method 
of treating the disease has been successfully practised by Dr. 
Engleman, a German physician. In all the cases in which it was 
used, ten in number, the method was followed by the absorption 
of the fluid and recovery of the patient. His method consists 
of the application of bandages and adhesive straps, which are 
renewed as the head diminishes in volume. The cases are de- 
tailed in the Archives de Medicine, for June, 1838. 



The ordinary affections of the organs of intellectual sensation, 
comprising those of sight and hearing, will necessarily form 
part of the diseases of the present system ; those connected with 
the corporeal or nutritive senses having already been considered. 
Such diseases of these organs only as are peculiar to children, 
will be the subjects of the present remarks: for those that are 
common to all ages, the reader is referred to works exprofesso 
on these subjects. 

OPHTHALMIA. 

Etiology. — This would appear at times a real congenital 
affection, for infants are seen born with the marks of inflam- 
mation that had evidently existed in the foetal state. For the 
most part, it appears within a week after birth, and arises either 
from the contact of the part with a vitiated secretion from the 
vagina of the mother, or from the stimulating influence of cold 
or too great heat, or from the effects of light or smoke. 

It is a very common occurrence to find it following leucor- 
rhea; indeed, when a woman has been thus disordered during 
gestation, the child will almost certainly be affected with some 
degree of ophthalmia. So, also, gonorrhoea will be invariably 
followed by this affection in the infant. 

At other times it appears to arise from the stimulating effects 
of light, smoke, or other external causes, acting directly on the 
eyes. When it is produced by these agents, it is later in its 
invasion than when it occurs from causes connected with par- 
turition ; scarcely, however, appearing after the fifth day. 
Neglect of cleanliness in not carefully washing the child, may 
become a cause of this affection, especially when any redness 
appears in them from an atmosphere filled with smoke. Badly 
ventilated apartments, it is well known, will cause a develope- 
ment of ophthalmia, and is one of the chief causes of its preva- 
lence in foundling hospitals. 



NERVOUS SYSTEM. 535 

Semeiology. — The disease sometimes appears immediately 
on the birth of the child, but in most instances does not show 
itself until the second or third day after birth, rarely after the 
fifth. It appears in two stages, the first of inflammation, the 
second of suppuration. 

The first appearance it exhibits is a slight inflammation, at- 
tended with a considerable degree of tumefaction. This is 
attended with a great aversion to light, the child keeping the 
eyelids closely shut in a lighted apartment, but will open them 
on the light being removed. When the inflammation is severe, 
it is evidently attended with pain, as indicated by the crying; 
and the intolerance of light is so great, that it is difficult to ob- 
tain a sight of the eyeball. 

After a short but indeterminate period the purulent stage 
commences, which is known by the increased swelling of the 
eyelids, and a discharge of pus taking place from between them. 
When they are separated, a great discharge ensues, and if the 
conjunctina can be seen, it appears to be excessively inflamed. 
The drying of the pus causes the eyelids to adhere, when the 
accumulation beneath them is often very great, and the tume- 
faction is excessive. At other times, small granulations are 
formed on the conjunctiva, and the swelling of the folds of this 
membrane forces the tarsi outwards, and produces a complete 
inversion of the eyelids. The purulent discharge is thick, and 
usually of a yellow colour, sometimes mixed with blood. In 
general, although the symptoms may be very severe, and the 
distension from the quantity of pus very great, the termination 
of infantile ophthalmia is favourable ; but cases of extensive 
sloughing or opacity of the cornea have occurred, where the 
affection has been much neglected, as is sometimes the case 
among the poor. 

Treatment. — The first stage of ophthalmia should be treated 
on strictly antiphlogistic principles ; by which, however, it is not 
meant that in every instance the abstraction of blood is needed ; 
this being only necessary in severe cases of inflammation. It 
will be often sufficient to keep the eyes well washed with tepid 
milk and water, or the mucilage of linseed or slippery-elm ; 
the latter, especially, has a remarkably soothing effect on the 
inflammation of these tender parts. This course, when adopted 
immediately on the appearance of inflammation, with an open 
state of the bowels, and great care being taken to keep the child 
from the light and smoke, will in many instances readily re- 
move the disease. 

As it is. however, very rapid in its progress, if it appear to 
be increasing, after the precautions above mentioned are used, 
a leech should be applied near the angle of the eye, but not 



536 DISEASES OP CHILDREN. 

directly to the inflamed part ; the wound should then be covered 
with a soft warm poultice. The subjoined formula may then 
be advantageously used, as an application to the inflamed eyes; 
but all astringent and stimulants should in this stage be 
avoided.* An aqueous solution of opium may be employed with 
very good effects where there exists much pain and intolerance 
of light. A solution of some of the salts of morphine, in the 
mucilages already mentioned, I have also used under these 
circumstances with benefit. At the same time more active 
effects should be produced on the bowels than above mentioned, 
by means of a small dose of calomel, to which may be added 
a quarter of a grain of ipecacuanha, if much febrile excitement 
be present. This course, followed by a small portion of castor 
oil from time to time, will keep the bowels free. A small 
blister ought also to be applied to the temples, or behind the ears. 
In the second, or purulent stage, astringent or stimulating 
collyria will be needed ; great care should, however, be observed, 
in not resorting to remedies of this nature at too early a period 
of the disease : the proper time for their use will be known 
by the disappearance of the excessive redness. A solution of 
the sulphate of zinc, in the proportion of a grain to an ounce 
of water, or two grains of alum to an ounce, may be used, and 
will in genera] effect a cure. In obstinate cases, the nitrate of 
silver will be found useful, in the proportion of two grains to the 
ounce, gradually increased to six grains. Any of these solu- 
tions may be injected between the eyelids three or four times 
in the course of twenty-four hours. 

OTITIS. 

Inflammation of the ear occurs frequently in children, from 
the great sensibility of the part, and for the same reason is a 
very painful affection. 

Etiology. — The most common exciting cause is cold, and 
especially the washing the head and neck with cold water, and 
from exposure of these parts to a stream of cold air. It is 
also produced by other diseases, as inflammations about the 
throat ; and, consequently, it, often follows an attack of scar- 
let fever, malignant sore throat, and ordinary tonsillar inflam- 
mation. 

Semeiology. — It is known by the pain in the ear, which is 
very severe and distressing, both from the great sensibility of 
the part, as from the tense and unyielding nature of the mem- 

* T$c Plumbi. Acetat., gr. iv. 
Aquae Dcstill., §iv. 
Mucilag. G. Acacia?, §ss. M. 



MOTOR SYSTEM. 537 

brane forming the tympanum. This -for the most part is con- 
fined to the ear itself, but not always ; as the side of the head, 
and even the brain, have become involved in the inflammation. 
When this occurs there is a great increase of the circulation, 
with heat, fever, thirst, delirium and stupor. The inflamma- 
tion will sometimes terminate in suppuration, and the discharge 
gradually changes its character to thin, offensive sanies, from 
the deep seated ulcers formed in the ear. 

Treatment. — The usual means for moderating inflamma- 
tion should be adopted in otitis. Often, however, the applica- 
tion of warmth and moisture to the part, by means of a poultice 
of hops, will have a very soothing effect, and if accompanied 
by purgatives and warm pediluvium. will arrest it at once. An 
ordinary poultice, with laudanum, will also be a useful remedy ; 
and when the pain is very severe, a few drops of laudanum 
and sweet oil on a small piece of cotton will afford great relief. 
If these measures are not followed by an abatement of the 
symptoms, either local or general bleeding will be necessary ; 
this should be followed by a continuance of the soothing local 
applications above mentioned. 

When suppuration is established, and the inflammatory 
symptoms have subsided, stimulating and astringent injections 
will be indicated, as the sulphate of zinc, in the proportion of 
two or three grains to an ounce of water. The chloride of 
soda, also, will be highly useful, especially when the discharge 
from the ear is offensive. In the chronic discharge from the 
ear, a general tonic course is required, while the part is kept 
well cleansed by injections of soap and w T ater, and gently sti 
mulated with the injections above mentioned. A permanent 
issue, also, will greatly assist in disposing the part to heal ; it 
should be placed on the back of the neck or on the arm. 



MOTOR SYSTEM. 

PECULIARITIES OF THE MOTOR SYSTEM. 

The bones connected with the limbs are, like the rest of the 
skeleton, in a very imperfect state of ossification at the period 
of birth ; the chemical constitution also differs at this period, and 
during childhood, from the bones of an adult. 

The different processes of the scapula are not perfectly 
united to the body of the bone until about the fourteenth year. 
The clavicle is one of the first bones formed, and during the 
foetal state is comparatively of a large size, and is of a full pro- 
portionate size in infancy. The humerus at birth is only one 

68 



538 diseases or children. 

nucleus of bone in the small head. The condyles are formed 
some time after birth, and are perfectly united with the body of 
the bone a considerable period before the full growth of the 
child. The same may be remarked with respect to the bones 
forming the fore-arm, the shafts being comparatively perfect, 
and the different processes not completely united to the body, 
until about the age of ten or twelve years. 

The bones forming the pelvis are much less developed in an 
infant, than the scapula and clavicle forming the bones of the upper 
extremities. All the bones composing the pelvis are separate ; 
and the three portions forming the ilium of a new-born child 
are not united until the seventh year. The femur observes the 
same laws in its developement as the humerus, but the union of 
the processes is much later than that of the first mentioned bone. 
The tibia and fibula are also rather later in the full disappear- 
ance of their cartilaginous portions. 

From the difference, therefore, in the developement of the 
upper and lower extremities, we see the cause of the greater 
ability of the child to use its arms and hands almost from the 
period of birth. The imperfect formation of the bones of the 
pelvis and lower limbs prevents the child from using them at 
all ; and the narrowness of the pelvis deprives it of the ability 
to sit, even if there existed muscular power sufficient to support 
the body in an erect position. 

During these alterations in the bones, the muscles undergo 
changes in their appearance, as they increase in cohesiun and 
solidity. They are at birth much lighter coloured and softer 
than at other periods of childhood. Gelatin abounds in infancy ; 
as age advances the proportion of fibrine increases. When 
the growth of the body is complete, their red colour is then 
strongly marked, and their power increases. 

As the bones and muscles change with the growth of the 
body, the child exerts his powers of movement, and all his mus- 
cles are in a continued state of activity. This restlessness is a 
peculiarity of childhood, and appears to be connected with the 
process of developement, as the muscular efforts are rather 
those of simple action than of power. 

Muscular exercise is essential to the proper growth of the 
body, and therefore the infant and child should be allowed to 
use such exercise as nature demands. Simple carrying is all 
that a young infant needs, and will often allay the accumulated 
excitability arising from the want of exercise. Premature 
attempts at making the child sit or stand are always injurious, 
by causing an undue pressure on the viscera of the abdomen 
and thorax. Active exercise in older children should be freely 
allowed, as nothing tends more to the full action of the nutritive 
process, and the proper developement of the body. 



MOTOR SYSTEM. 639 



SIGNS OF DISEASE FROM THE MOTOR SYSTEM. 

The excessive increase in the length of the bones is a frequent 
occurrence after exanthematous fevers ; and rachitis is not an 
unusual consequence of this derangement of nutrition. In pro- 
tracted disease it is a sign of debility, and yields an unfavour- 
able prognosis. When the bones are suddenly developed in 
youth, without any apparent disease, it has been supposed to 
indicate a premature developement of the sexual instinct. 

The bones of the foot are often changed in their form from 
the powerful action of one set of muscles, producing club-foot; 
so, also, curvatures of the spine may occur from a preponderance 
of action in some of the muscles. 

Enlargement of the ends of the bones is an evidence of the 
existence of scrofula and rickets; it is very common also after 
severe cases of scarlet fever or measles. 

The muscles usually diminish in size after the continuance of 
any febrile disease ; but this of itself is not to be regarded as 
unfavourable. If this wasting continue after the disappearance 
of fever, or when it attends chronic disease, it is decidedly 
unfavourable, as it indicates the existence of disorganization. 
The wasting of the spinal muscles marks the existence of tabes 
dorsalis. 

The sudden increase of muscular activity in a young child, es- 
pecially if accompanied with great exhilaration of spirits, denotes 
an increased circulation of the brain, and often precedes sudden 
attacks of hydrocephalus. 

Lassitude and weariness are very common in children 
before acute diseases, especially those of a contagious nature: 
muscular debility being always produced by the influence of 
contagion, and is a good diagnosis of the disease during the 
prevalence of epidemics. A prognosis may also be made from 
the extent, of debility during the continuance of acute diseases, 
as it always marks the extent of the disease, and denotes the 
affection of some important organ. 

The sudden loss of muscular power gives a very unfavour- 
able prognosis ; and the total want of ability in a child to stand, 
denotes a serious affection of the brain, and is usually the pre- 
cursor of the sudden effusion denominated water stroke. The 
alternation from great debility to increase of strength in chronic 
diseases is also an indication of cerebral disease, and is a much 
more unfavourable sign than the cuntinuance of debility. 

Great restlessness, and involuntary movements of the muscles 
in long continued disease, are unfavourable signs, and usually 
denote cerebral disease. 

Convulsions and spasms usually proceed from irritation, in- 



540 DISEASES OF CHILDREN. 

flammation, or other affections of the brain and spinal cord. 
In other instances they appear to depend solely on the irritation 
of the ganglionic nerves, from worms or other irritation in the 
stomach and bowels ; when this is the case, there is but little 
or no cerebral disturbance, and the child, if old enough, will 
perhaps recollect and describe the occurrences which took 
place during the paroxysm, although unable at that period to 
articulate. 

Spasms affect either the whole body or a certain set of 
muscles ; and in chorea, the spasmodic action occurs in different 
muscles in succession. When spasms affect the muscles of 
the face alone, it is a more unfavourable sign than when any 
other set of muscles are affected. Spasms in children are 
much less dangerous than in adults ; but when they occur in 
chronic diseases, they give in all a bad prognosis. When pro- 
ceeding from gastric irritation, worms, or dentition, they are 
not in general to be regarded as dangerous. Other affections 
of the muscles are considered under the signs of disease from 
the influence of the nervous system. 

DISEASES OF THE MOTOR SYSTEM. 
ABSCESS OF THE HIP JOINT. 

Abscess of the hip joint, or morbus coxarius, is a disease very 
insidious in its approach, and often makes rapid progress to- 
wards the destruction of the bones forming the joint, and con- 
sequently producing irremediable lameness before it is dis- 
covered. A close watchfulness, therefore, becomes necessary, 
that the disease may be detected, and the remedies applied in 
its incipient stage. 

Etiology. — A scrofulous habit of body appears, in some in- 
stances, to predispose the joint of the hip to inflame, suppurate, 
and become carious, for it is difficult to trace the disease to any 
other source than the spontaneous occurrence of inflammation, 
which is apt to arise in such conditions of system. It has been 
supposed at other times to arise from the injuries children receive 
in their sports. 

Semeiology. — The first sign of the existence of the hip dis- 
ease, is the inability to move both limbs equally: one of them 
appears to drag while the other is properly moved. A child, 
also, that has this affection, in its forming stage, will be often 
seen to fall, as if tripped by the carpet. This arises from the 
toes of the affected limb being a little inclined downward when 
the foot is raised ; no complaint being made, the existence of 
disease is not even suspected from this circumstance, but the 
child is supposed to have met with an ordinary fall, to which it 
is so liable in its sports. 



MOTOR SYSTEM. 541 

The affected limb, when compared with the other, is dis- 
covered to be a little shorter ; and when the presence of dis- 
ease is evident, its nature is still mistaken, for the child refers 
his uneasiness to the knee and lower part of the thigh. As it 
advances, the rotundity of the affected hip disappears, and a 
more marked shortness of the limb is noticed, while the child 
evidently limps in walking. By a careful examination, the seat 
of the disease will easily be discovered, principally by flexing 
the limb with the hand ; the knee, where most pain is felt, being 
easily moved. 

After the affection has continued for some time, suppuration 
will take place, and the bones of the joint will be involved in the 
disorganization and become carious. An abscess forms and 
discharges an unhealthy pus ; great prostration ensues, and the 
patient dies in great exhaustion. 

Treatment. — The treatment in the first stage must consist of 
the usual means of allaying inflammation, while the limb is kept 
at perfect rest. When there is much heat of the surface and 
activity of the pulse, the child should be bled from the arm, and 
the bowels freely opened by active purgatives. These should 
be repeated if there is a continuance of the pain and fever. 
The hip, also, ought to be leeched or cupped, if the pain and 
other evidences of inflammation continue unabated; local san- 
guineous depletion should always be used when bleeding from 
the arm is counter-indicated by the debility of the child. A 
constant open state of the bowels must be preserved by means 
of daily purgatives, suited to the age and strength of the pa- 
tient ; the puivis purgans and calomel may form the first purga- 
tive mixture, followed by an infusion of senna every day or 
two in a robust child, until a sensible reduction of the pulse 
takes place. The child should be kept, if it be possible, con- 
stantly lying on a hard mattress, and no opportunity whatever 
of exercising the limb afforded until an entire cure is effected. 
Where this cannot be accomplished in a young child, the use 
of a splint adapted to the part may prevent the movements of 
the limb. 

With this course, adopted in the stage of inflammation, a 
cure will in most cases certainly follow ; but where the disease 
is left until suppuration, or disorganization has occurred, very 
little can be done to prevent a permanent lameness. In this 
stage it is often very much protracted, and attended with great 
suffering, prostration and emaciation. In the early part of the 
suppurating stage, if the child retain sufficient strength, a per- 
manent issue should be made near the affected joint, and the 
usual hygeinic measures of a change of air, or a residence near 
the sea in hot weather, cold bathing and a nourishing course 



542 DISEASES OF CHILDREN. 

of diet adopted, to impart energy and vigour to the constitution, 
so necessary to enable the child to resist the effects of con- 
tinued irritation, and the exhaustion from the excessive drain. 

CLUB-FOOT. 

Distortions of the feet, from the time of Hippocrates until 
the close of the last century, attracted but little attention from 
surgeons ; and the only method of cure attempted was the ap- 
plication of bandages and other mechanical contrivances, for 
the gradual adjustment of the distorted and displaced bones, 
At this period, important improvements were suggested by 
Lorenz, a surgeon in Frankfort, at the suggestion of Thilenius, 
a physician of that city. 

In the year 1838, Dr. Louis Stromeyer, of Hanover, publish- 
ed an essay on the subject of orthopoedia, with practical obser- 
vations on the division of contracted muscles and tendons. The 
next work of note appeared in London, in the year 1839, by 
Dr. W. J. Little, in which the nature and treatment of club- 
foot are considered at length. This important subject has re- 
ceived the attention of surgeons in the United States, and addi- 
tional suggestions have been made by Dr. Thomas D. Mutter, 
of Philadelphia, and Dr. W. Detmold, of New- York.* A few 
practical suggestions occur in the various medical periodicals, 
but the above comprise the monographs that have been pub- 
lished on the subject. 

Etiology and Semeiology. — Congenital club-foot was for- 
merly attributed to a malformation of the astragulus and other 
tarsal bones, and on this account the replacement was consi- 
dered a very difficult operation, if, indeed, it could be per- 
formed at all. Subsequent observations, however, have shown 
that it is in most instances referable to the contractions of the 
muscles, arising from a primary affection of the nervous centre, 
causing convulsions which the fcetus surfers. These distortions 
have been found in foetuses of from three to five months old, 
where there were deficiencies and malformations in the cere- 
brum and medulla spinalis ; and anencephalus and hemicepha- 
lus embryos have exhibited both hands and feet distorted in that 
manner. The affection has been known to be hereditary, arising 
from the transmission of the irritability of the nervous system, 
producing convulsions and spasmodic contraction of the muscles. 

It may also arise after birth from a similar cause, producing 
paralysis of the muscles ; when on a partial recovery, the 

» A Lectureon Loxarthus, or Club-foot, by Thomas D. Mutter, M. D.j Phila- 
delphia, 1839. An Essay on Club-foot, etc., by W. Detmold, M. D. ; New- York, 
184a 



MOTOR SYSTEM. 543 

flexor muscles act more powerfully than the extensors, and thus 
cause the distortions of those parts more easily affected by the 
powerful action of the muscles, and which also, from the arrange- 
ment of their bones, more easily yield to this unequal action. 

Club-foot has been divided into four species by Dr. Little, 
with the generic appellation of Talipes ; these being of prac- 
tical use, are now generally adopted to describe the various dis- 
tortions of the foot. 

The first, Talipes varus, is where the heel is drawn up and 
the foot turned inward ; the toes are also turned inward, and 
the^ patient walks on the outer ankle. It is produced by the 
contraction of the gastrocnemii and the adductors of the 
foot. 

The second species, Talipes valgus, is where the foot is turned 
outward, and where the patient walks on the inner ankle. The 
gastrocnemii and the abductors of the foot are here con- 
tracted. 

The third, Talipss equinus, where the gastrocnemii muscles 
are contracted without any affection of the others. In this spe- 
cies the patient walks upon the toes. 

The fourth, Talipes calcaneus, is caused by the contraction of 
the muscles in front of the leg ; when the patient walks on the 
heel. 

Treatment. — The improvement in the treatment of club- 
foot is one of the greatest triumphs in modern surgery, whether 
it is regarded as the results of the accurate knowledge of the 
morbid condition of the part, or the benefits which result from 
the means used to remedy this deformity. 

The indications of cure are to remedy the contractions of the 
muscles producing the deformity, and to afford an opportunity 
to those which act in opposition, to recover their power of 
action. These are accomplished by means of apparatus adapted 
to the extension of the contracted muscles, the extension to be 
gradually but steadily increased until the permanent contrac- 
tion is overcome ; or by a resort to the section of the contracted 
muscle or the tendon connected with it. 

The division of the tendo Achillis was first resorted to for 
the cure of club-foot, in the year 1784, by Lorenz, of Frankfort. 
With some variations in the details, the same operation was per- 
formed by Michaelis and Sartorius ; and about the year 1816, 
by Delpech, in France; but owing to its failure, a number of 
years elapsed before recourse was again had to the knife. In 
1831, Dr. Stromeyer, of Hanover, undertook the operation 
with complete success. Since this period it has been the 
usual resource for the removal of deformities of the limbs, 
by a number of surgeons in Europe and America. It was first 



544 DISEASES OF CHILDREN. 

performed in the United States by Dr. James H. Dickson, of 
North Carolina, in 1835, and by Dr. N. R. Smith, of Baltimore, in 
1836, and in the following year by Dr. Detmold, of New- York. 
It is not within the limits prescribed to this work, to describe at 
length the operation of tenotomy, which has of late years been so 
successful in the removal of the deformities of the feet and limbs ; 
the works already mentioned contain a great amount of prac- 
tical matter on this subject, and are in the hands of every sur- 
geon. However important and successful the division of ten- 
dons may have been, it is not to be resorted to on all occasions, 
and an unneccessary number cut. On this subject Dr. Detmold 
makes the following judicious remark : u We are far from sanc- 
tioning an indiscriminate use of the knife, and if a little more 
patience and attention on the part of the surgeon will render 
the division of the muscle unnecessary, we consider it the urgent 
duty of every surgeon not to yield to a fondness for operating, 
but be guided solely by the result of a conscientious examina- 
tion in deciding that the knife is absolutely necessary, or at least 
preferable." 



INDEX. 



Air, pure, necessary for children, 25 

Asphyxia, 32 

Etiology of, 32 

Semeiology of, 35 

Pathology of, 36 

Treatment of, 36 

Apoplexy, Congenital, 34 

Auscultation in Bronchitis, 42 

Pneumonia, 53 

Pleurisy, 62 

Aphthae, 143 

A mulet, Coral, in teething, 161 

Absorbent System, Activity of, in chil- 
dren, 272 

Alopecia, 350 

Artificial Feeding, 190 

Animal Functions, 486 

Bronchitis, 40 

Etiology of,. . 41 

Semeiology of, 41 

Morbid Anatomy of, 43 

Treatment of, 43 

Blood, quantity of, in the child, 115 

Baldness, 350 

Burns, 350 

Treatment of, 352 

Cry of an Infant, 27 

Crying, the various kinds of, 30 

Cough, different kinds of, 30 

Cord, different conditions of, a cause of 

Asphyxia 33 

Period for tying, 39 

Catarrh, 42 

Catarrhal Congestive Fever, 43 

Treatment of, 47 

Coryza, 64 

Etiology of, 64 

Semeiology of, 64 

Morbid Anatomy of, 65 

Treatment of, 65 

Croup, History of, 66 

Inflammatory, 70 

Etiology of, 70 

Semeioloey of, 71 

Treatment of, 78 

Spasmodic, History of, 91 

Etiology of, 92 

Semeiology of,. .. 93 

Treatment of,. ... 95 

Complications of Hooping-Cough,... . 100 

Convulsions, 494 

Semeiology of, 496 

Morbid Anatomy and Pa- 
thology of, 498 

Treatment of, 499 



Circulatory System, Ill 

Signs from,, 115 

Diseases of,. 1 17 

Cyanosis, 117 

Etiology of, 117 

Semeiology of, 119 

Treatment of, 120 

Corpo Pedal Spasm, 159 

Cynanche Maligna, 167 

Etiology of, 168 

Semeiology of, 169 

Pathology of, 170 

Treatment of, 171 

Catamenial Discharge affects the milk, 1£0 
Cholera Infantum, History and Eti- 
ology of, 213 

Semeiology of,.. . 215 
Morbid Anatomy 

and Pathology of, 217 
Treatment of, ... . 219 

Constipation, Etiology of, 229 

Semeiology, Pathology 

and Treatment of, 230 

Cutaneous System, peculiarities of,. .. 274 

Cutaneous Diseases, 337 

Etiology of, 339 

Pathology of, 343 

Arrangement of,.. 346 

Crinones, 349 

Chilblains, 354 

CrustaLactea, 362 

Colic, 182 

Contractions of Tendons after Scarlet 

Fever, 408 

Chorea, 502 

Etiology of, 503 

Semeiology of, 503 

Morbid Anatomy and Patho- 
logy of, 504 

Treatment of. . 50 1 

Club-Foot, '. 542 

Etiology and Semeiology of, 542 

Treatment of, 543 

Divisions of the Diseases of Children, 2 
Disorder of Function important to con- 
sider in ail diseases, 3 

Developement of the Body, a great 

source of disease, 17 

Ductus Arteriosus, obliteration of, Ill 

Digestive System, 130 

Signs from, 140 

Diseases of, 143 

Dentition, Morbid, 156 

Etiology of, 156 

Semeiology of, 158 



69 



546 



INDEX. 



PAOR. 

Dentition, Morbid Anatomy of, 160 

Treatment of, 160 

Diet in Teething Children 163 

Diarrhoea, 194 

Feculent, Etiology of, 195 

Pathology and Treat- 
ment of, 196 

Serous, Etiology, Semeiolo- 

gy, Pathology of,.. 200 

Treatment of, 201 

Bilious, Etiology of, 202 

Semeiology of, 203 

Treatment of, 204 

Mixed and Chronic, 205 

Etiology and Semei- 

ology of,. 207 

Morbid Anatomy of, 208 

Treatment of, 210 

Dysentery, Etiology of, 262 

Semeiology and Pathology 

of,....: ".. 263 

Treatment of, 264 

Dysuria, Etiology and Semeiology of,. 326 

Treatment of, 7 327 

Diabetes, 33 1 

Etiology of, 332 

Semeiology of, 333 

Pathology V, 334 

Treatment of, 355 

Dropsy after Scarlet Fever, 407 

Emeries, Vitriolic, in Croup, 87 

Emetic, Tartar, its danger, 44 

Enteritis, Etiology and Semeiology of, 254 
Morbid Anatomy of,.. .7. . . . 258 

Treatment of, 259 

Excernent System, 271 

Signs from, 279 

Diseases of, 283 

Encnusis, , 350 

Erysipelas, Etiology of, 365 

Semeiology of, 366 

Treatment of, 367 

Eczema, 378 

Ecthyma, 391 

Fluids, importance of changes in,. ... 4 
Constitute a large portion of the 

body of a child, 11 

Foramen Ovale, obliteration of, Ill 

Food, improper, «i cause of iud.gestion, 1S1 

Fruits, use of, fir children, 181 

Feeding, Artificial, 190 

Furunculus, 333 

Growth, importance of, in considering 

the Diseases of Children, 1 

Glottis, size of the, 23 

Gangrenous Erosion of the Cheek,... 146 

Gastritis, Etiology of, 251 

Morbid Anatomy of, 252 

Semeiology and Treatment 

of, 253 

Hooping-Cough, History of, 97 

Etiology of, 97 

Semeiology of, 98 

Morbid Anatomy and 

Pathology of, 101 

Treatment of, 104 

Heat of the Foetus and Child, Ill 

Pulsations of, 113 

Hepatic Affections, 227 



PAGE. 

Hernia?, Etiology and Semeiology of, 269 

Treatment of, 270 

Herpes, 3S0 

Hydrocephalus, 506 

Acute, 506 

Etiology of, 507 

Semeiology of, 511 

Morbid Anatomy of,... 5i9 

Treatment of, 5 : <2 

Chronic, Etiology of,.. 529 

Semeiology of, 530 

Pathology, of, 531 

Treatment of, 533 

Hip Joint, Abcess of, 540 

Etiology and Semeiology of, 540 

Treatment of, ." ... 541 

Independent Life, Changes in Circula- 
tion, 1H 

Indigestion, Infantile, Etiology of,. . . . 178 
Semeiology of, . 182 
Morbid Anato- 
my of, 184 

Treatment of,... 185 

Integuments, co'our of, in Infants, 276 

Incontinence of Urine, Etiology and 

Semeiology of, ' 323 

Treatment of, 325 

Intertrigo, 356 

I mpetigo, 360 

Jaundice, 369 

Joints, Affections of, after Scarlet 

Fever...... 408 

Life, views of its nature, 6 

Larynx of Children, size of 23 

Lungs of the Children, 24 

Lobular Pneumonia, 55 

Lobar Pneumonia, 57 

Lymphatic System, peculiarities of,.. 271 

Lichen, 376 

Moaning, its indication, 29 

Malformation of the Thorax, a cause 

of Asphyxia, 35 

Millar's Asthma, ' 91 

Mouth, Ulcerated, 143 

Milk, by what affected, 179 

Properties of good, 191 

Meconium, retention of, 229 

Motor System, 537 

Peculiarities of, 5:7 

Signs of Disease from,. 539 

Morbus Coxarius, 5:0 

Ncevi Maierni, 346 

Nettle Rash, 374 

Nervous System, 486 

Peculiarities of, 486 

Signs of disease from, 490 

Diseases of, 494 

Oesophagitis, Etiology and Semei- 
ology of, 176 

M oi bid Anatomy and 

Treatment of, 177 

Ophthalmia, Etiology of, 534 

Semeiology of, 535 

Treatment" of 535 

Otitis, Etiology and Semeiology of,. .. 536 

Treatment of, 537 

Preliminary Observations, 1 

Percussion, peculiarities from, 25 

How employed in Children, 32 



INDEX. 



547 



Parents, extreme youth of, a cause of 

Asphyxia .' 33 

Placenta, detachment of, a cause of 

Asphyxia, 34 

Pneumonia, 49 

Etiology of, 50 

Semeiuloey of,. 51 

Morbid Anatomy and Pa- 
thology of, 55 

Treatment of, 58 

Percussion in Bronchitis, 42 

Pnenmonin, 53 

Pleurisy , 62 

Pertussis 97 

Pulse of Children, 113 

Sign* from, 116 

Parotitis, Etiology and Pathology of,. 174 

Treatment of, 7 175 

Passions affect the milk ]B0 

Peritonitis. Etiology of, 266 

Semeiology, Morbid Ana- 
tomy and Treatment of, 267 

Pernio, 354 

Prurigo, 359 

Poriigo Larvalis, 362 

Purpura, 331 

Psoriasis 384 

Porrigo Favosa, , 385 

Pemphigus, 390 

Respiratory System, 23 

Peculiarities of,... 23 
Signs of diseases 

from 28 

Respiration, Peculiarities of, 25 

How first effected, 25 

Different kinds of, 30 

Remittent Fever, 1 20 

Etiologvof, 120 

Semeiology of, 121 

Morbid Anatomy and 

Pathology of, 124 

Treatment of, 127 

Rickets, Etiology of, 318 

Semeiology of, 319 

Pathology of 320 

Treatment of, 321 

Retention and Suppression of Urine, 

Eliulogy and Semeiology of, 329 

Treatment of, 330 

Running Tetter, 360 

Roseola, 377 

R"pia,.. 392 

Rheumatic Affections of Joints after 

Scarlet Fever 408 

Rubeola — Measles, 424 

Etiology of, 424 

Semeiology of, 4C6 

Morbid Anatomy and Patho- 
logy of, 430 

Treatment of, 430 

Solids, the great attention to, 4 

Stomach of an Infant, 13 

Stomatitis, 143 

Etiology of, .' 144 

Serripiology of, 145 

Morbid Anatomy of, 147 

Treatment of, ]50 

Swelling of the Hands and Feet, 159 

Stomach and Intestines, diseases of,.. 178 



Suckling, Protracted, its effects, 180 

Scrofula, Historv'of, £83 

Etiology of, £34 

Semeioiogy of, 283 

Pathology ol 2*9 

Treatment of, 295 

Strophulus, 357 

Scarlatina, 393 

Etiology of, 394 

Semeiology of, S97 

Sequela? of, 4f7 

Suppurations of Glands after 4fS 

Morbid Anatomy of, 469 

Treatment of,.. ." 412 

I Syphilis, 478 

Treatment of, 481 

Scabies, 4£3 

Treatment of, 484 

Trachiae, peculiarities of, 23 

Thorax, size of, 24 

Tempprature, uniform, the necessity of, 48 

I Teething, process of, 132 

Tongue-Tie, 155 

Tonsillitis, K 4 

Ktiology of, 164 

Pathology and Tieatmentof, 165 

Tabes Mesenterica, "." 304 

Etiology of, 305 

Semeiology of, 3f 7 

Pathology of, 311 

Tieatmentof, 3' 3 

Tinea, 38G 

Tendons, C01 tractions of, after Scarlet 

Fever,... 463 

Urine, Incontinence of, 323 

Retention and Suppression of',.. 3i9 

Uilirni-ia, 374 

Vitality, its nature considered, 6 

Its action in Adults, 17 

Child. en 17 

Vital Function?, 23 

Voice of Childhood, 57 

Vomiting, Physiology of, 136 

Verrucae, ". M 348 

Vesication, 356 

Varioloid, 449 

Varicella— Chickeu-Pox 452 

Etiology of.. '52 

Vaccinia — Cow-Pox, '. 4 5 

Experiments on,.. 457 

Vaccination, 461 

Statistical Results of,. .. 475 

Variola— Small-Pox 4 6 

Etiology of, 4'-7 

Semeiology of. . .. 4C9 
Moibid Anatomv 

and Pathology of, 443 
Treatment of,.". . . 444 

Worms, Hi=torv of, 2?5 

Etiology of '.39 

P.'iihologv and Semeiology of, 242 

Treatment of, 245 

Supposed to lie a cause of 

Remittent Fever, 125 

Weaning Brash 181 

Time for, 193 

Wnrts 348 

Wet Nurse, preferable to artificial food, 190 
Yellow Gum, 369 






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13 



